Knowledge Base Article

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just thirty days on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

CMS released Change Request (CR) 9533 on February 19th and related MLN Matters® article MM9533. Both are aimed at Provider Education with emphasis on the need for Providers to make sure that billing staff is aware of the changes.  

Demonstration Code 75

CMS will automatically apply the CJR Demonstration Code 75 to claims that meet criteria for inclusion in this project. Medicare beneficiaries to be included in this model must meet the following criteria:

• Enrollment in Medicare Part A and Part B;
• Medicare eligibility is not based on the End-Stage Renal Disease benefit;
• Not being enrolled in any managed care plan;
• Not being covered under a United Mine Workers of America health plan; and
• Medicare is the primary payer.

CMS notes that, if at any time during the episode the beneficiary no longer meets all of these criteria, the episode is cancelled.

CMS instructs that they will automatically apply Demonstration Code 75 when the inclusion criteria are met and that “participant hospitals need not include demonstration code 75 on their claims.” They go on to note that instructions for submission of claims for Skilled Nursing Facility (SNF) services will be communicated when the waiver of the three-day stay requirement is operationalized.

Billing and Paying for Post-Discharge Home Visits

In the CJR Final Rule, CMS finalized their proposal “to waive the “incident to” direct physician supervision requirement set forth at §410.26(b) (5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

This service will be billed under the Medicare Physician Fee Schedule (MPFS) with a HCPCS G-Code (G9490). This G-Code will be payable for CJR model beneficiaries beginning April 1, 2016. “Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code.

Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year.”

Billing and Payment for Telehealth Services

CMS also finalized to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Waiver of the telehealth requirements will be subject to certain conditions that have been detailed in CR 9533 and MLN MM9533.

As with the Post-Discharge Home Visits, Telehealth Services will also be billed under the MPFS using one of nine HCPCS G-codes (G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, and G9499). Attachment A of CR 9533 provides the long descriptors of these codes. These codes will also be payable beginning April 1, 2016.

“Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code.” Similar to guidance for post-discharge home visits, no demonstration code is needed or required on Part B claims submitted with a post discharge telehealth visit HCPCS G-code. “Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year.”

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.