COVID-19 and CJR: Public health emergency drives additional changes

DATE: 12/02/2020

The COVID-19 public health emergency has resulted in numerous federal policy and program changes. Comprehensive Care for Joint Replacement program participants need to be aware of and prepared for several program changes in one of the most recent, CMS’ Additional Policy and Regulatory Revisions in Response to the COVID-19 PHE, released Oct. 28.

First, the current CJR program’s performance year 5 will be extended by an additional six months, changing the program end date to Sept. 30, 2021. This change aims to prevent disruptions to the model’s current operations if the PHE continues through March 2021. This also means that there will be some changes to the proposed three-year extension to CJR. CMS is seeking comments on how to handle the three-year CJR extension (PYs 6-8) and is assessing if PYs 6-8 should remain 12-month performance years or if PY6 should be adjusted to cover 15 months to allow it to end with the calendar year.

CMS modified the reconciliation process for PY5, which is now separated into two distinct periods for reconciliation. PY5 reconciliation 1 covers episodes that end in calendar year 2020, while PY5 reconciliation 2 covers episodes that end between Jan. 1, 2021 and Sept. 30, 2021. Since the extension makes PY5 nearly twice as long as originally intended, hospitals will now get more timely results on their quality performance and cost-savings efforts. Participants should be on the lookout for reconciliation results in late February 2021 at the earliest, as has been customary in previous years.

Two new Diagnosis Related Groups (521 and 522) for patients with hip replacements following hip fractures will now be included in CJR. These DRGs were introduced in the federal fiscal year 2021 Inpatient Prospective Payment System/long-term care hospital final rule, which took effect Oct. 1. Inclusion of a patient in CJR was initially based on DRGs 469 and 470 only and the interim final rule enables the CJR inclusion of DRGs 521 and 522. The target price methodology includes the application of update factors for each of the payment systems and will therefore accommodate the new payment rates associated with the new DRGs.  These episodes typically account for 20% to 25% of all lower extremity joint replacement episodes.

Finally, the extreme and uncontrollable circumstances (EUC) adjustments for COVID-19 in CJR expire on March 31, 2021 or the last day of the PHE period, whichever comes sooner. CMS has defined an end date to this adjustment since CJR episode volume has begun to increase again following expiration of federal guidance to avoid elective surgeries. Currently, the EUC adjustment for COVID-19 in CJR removes downside risk for episodes in hospitals located in the emergency area for the PHE. Once either the PHE expires or by March 31, 2021, CMS will remove downside risk in CJR only for episodes with a COVID-19 diagnosis.

There are many changes to take in and keep track of during an already challenging time. Fortunately, these changes will help CJR participants stay afloat while elective surgeries continue to increase to normal volume and will provide continuity in the program while the new version of CJR is being finalized. To find out more about how to embrace these changes, visit today to request a free consultation.

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