Consider preparing now for CJR-X, CMS’s mandatory joint replacement model affecting hospitals nationwide starting January 1, 2028.
As anticipated, the proposed Comprehensive Care for Joint Replacement — Expanded model, or CJR-X, is now finalized. CJR-X is a national, mandatory, value-based care model from Medicare covering hip, knee, and ankle surgeries for Fee-For-Service Medicare beneficiaries.
The model launches January 1, 2028. There is no stated end date.
Mandatory hospital participation
Participation isn’t optional. All acute care hospitals eligible for payment under the inpatient and outpatient prospective payment systems (PPS) in all 50 states, the District of Columbia, and U.S. territories are in.
Hospitals already mandated to participate in the TEAM bundled model and Maryland hospitals are exempt from the model. Plus, facilities not paid under the PPS are not impacted:
- Critical access hospitals
- Rural emergency hospitals
- Indian Health Services and Tribal facilities
- Rural Community Hospital Demonstration participants
Hip, knee, and ankle replacements
The model covers lower extremity joint replacements (LEJR) — hips, knees, and ankles — in both the inpatient and outpatient hospital setting. An episode includes the inpatient “anchor hospitalization” or “anchor procedure” plus 90 days after hospital discharge.
The episode triggers from six different codes (see table). To determine which patients are included, in general, the model uses an 180-day lookback ending the day before the anchor procedure or hospitalization for Medicare fee-for-service beneficiaries.
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CJR-X Codes Triggering Episodes |
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Inpatient Medicare Severity Diagnosis Related Codes (MS-DRGs) |
Outpatient Healthcare Commone Procedure Coding System (HCPCS) |
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Benchmarks, target prices, stop-loss, stop-gain payments
Hospitals are held accountable for the cost and quality of care during the entire episode. They are given target prices based on regional benchmarks adjusted by various factors.
Adjustments include prospective trend, discount, and normalization factors plus risk adjustments. Risk adjustments for hospitals are at two levels — facility-level and beneficiary level. Facility-level factors include bed size and safety net status.
Beneficiary-level factors include age, HCC score, beneficiary economic risk, prior post-acute care use, disability status as the reason for initial Medicare enrollment, and recent medical history.
Reconciliation payments are what hospitals either earn back or pay back based on their performance. Hospitals with efficient costs and high quality can earn up to 20% back (stop-gain) while inefficient and lower-quality performance can result in losses up to 20% (stop-loss).
A low-volume threshold exists for rural hospitals with fewer than 31 LEJRs plus a stop-loss limit of 5% for Medicare-dependent, sole community hospitals, rural, and certain safety-net hospitals. The quality composite score (QCS) impacts these reconciliation payments.
The QCS is based on five measures, three of which are tied to inpatient surgeries and two to outpatient procedures. The measures are weighted — 50% for complications, 40% for patient experience, and 10% for patient-reported outcomes — and rolled into the QCS.
Collaborators and financial risk sharing
Since hospitals are held accountable for the cost and quality of an entire 90-day episode, many may want to work with other “collaborators.” Collaborators must provide certain activities that relate to the model and can enter into risk-sharing arrangements. The following are eligible to serve as collaborators:
- Skilled nursing facilities
- Home health agencies
- Long-term care hospitals
- Inpatient rehab facilities
- Physicians
- Nonphysician practitioners
- Therapists in private practice
- Comprehensive outpatient rehab facilities
- Outpatient therapy providers and suppliers
- Physician group practices
- Hospitals
- Critical access hospitals
- Non-physician provider group practices
- Therapy group practices
- Medicare accountable care organizations
Several waivers are also available in this model, including post-discharge home visits, telehealth flexibilities, and waiving the required three-day inpatient stay for SNF coverage.
How CLA can help with CJR-X implementation
CJR-X is a major model, and the first mandatory national model of its type. The January 1, 2028, launch date gives hospitals a defined runway for preparation. Steps to take now are:
- Determine whether your hospital is impacted by CJR-X or if it qualifies under an exemption
- Review full model details
- Assess volumes and spending for LEJR episodes
- Review current quality scores for QCS measures
- Begin to consider whether/who to have as collaborators
If you have questions or need help moving forward, reach out to CLA’s health care professionals today. We’re here to help.