E/M Not Part of CJR Model in Quality Payment Program
It’s essential for applicable providers to know how the definition of an attribution-eligible Medicare beneficiary for the Advanced Alternate Payment Model (APM) track of the Comprehensive Care for Joint Replacement (CJR) Model for the purposes of making Qualifying APM Participant determinations in the Quality Payment Program (QPP).
In a fact sheet, posted Dec. 6 on qpp.cms.gov, the Centers for Medicare & Medicaid Services (CMS) compares the standard definition of an attribution-eligible beneficiary under the QPP to that of the CJR Model.
The Making of a Subset
Whereas evaluation and management (E/M) claims are the basis for the standard definition of an attribution-eligible beneficiary, the CJR Model is based on discharges from a CJR participant hospital under Medicare Severity-Diagnosis Related Group (MS-DRG) 469 Major joint replacement or reattachment of lower extremity with major complications or comorbidities or 470 Major joint replacement or reattachment of lower extremity without major complications or comorbidities. As such, CMS has established a subset of the attribution-eligible population.
An attribution-eligible beneficiary for the CJR Model for purposes of the QPP is someone who:
(1) Is not enrolled in Medicare Advantage or a Medicare cost plan;
(2) Does not have Medicare as a secondary payer;
(3) Is enrolled in Medicare Parts A and B;
(4) Is at least 18 years of age;
(5) Is a United States resident; and
(6) Is furnished covered professional services by an eligible clinician affiliated with a CJR participant hospital.
CMS also stipulates that, under the CJR Model, the beneficiary must not be eligible for Medicare on the basis of end-stage renal disease; must not be covered under a United Mine Workers of America health plan; and must not aligned to certain Accountable Care Organizations.