Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to…

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)

SUMMARY: This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

EFFECTIVE DATE: Effective dates: This rule is effective February 18, 2017, except for the following amendatory instructions: number 3 amending 42 CFR 510.2; number 4 adding 42 CFR 510.110; number 6 amending 42 CFR 510.120; number 14 amending 42 CFR 510.405; number 15 42 CFR 510.410; number 16 revising 42 CFR 510.500; number 17 revising 42 CFR 510.505; number 18 adding 42 CFR 510.506; and number 19 amending 42 CFR 510.515, which are effective July 1, 2017.

Applicability date: The regulations at 42 CFR part 512 are applicable July 1, 2017.

FOR FURTHER INFORMATION CONTACT: For questions related to the EPMs: EPMRULE@cms.hhs.gov.

For questions related to the CJR model: CJR@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

Electronic Access

This Federal Register document is also available from the Federal Register online database through Federal Digital System (FDsys), a service of the U.S. Government Printing Office. This database can be accessed via the internet at http://www.gpo.gov/fdsys/.

Alphabetical List of Acronyms

Because of the many terms to which we refer by acronym, abbreviation, or short form in this final rule, we are listing the acronyms, abbreviations and short forms used and their corresponding terms in alphabetical order.

ACE Acute-care episode

ACO Accountable Care Organization

ALOS Average length of stay

AMA American Medical Association

AMI Acute Myocardial Infarction

APM Alternative Payment Model

APRN Advanced Practice Registered Nurse

ASC QRP Ambulatory Surgical Center Quality Reporting Program

ASC Ambulatory Surgical Center

ASPE Assistant Secretary for Planning and Evaluation

BAA Business Associate Agreement

BPCI Bundled Payments for Care Improvement

CABG Coronary Artery Bypass Graft

CAD Coronary artery disease

CAH Critical access hospital

CBSA Core-Based Statistical Area

CC Complication or comorbidity

CCDA Consolidated clinical document architecture

CCDE Core clinical data elements

CCN CMS Certification Number

CEC Comprehensive ESRD Care Initiative

CEHRT Certified Electronic Health Record Technology

CEP Clinical Episode Payment

CFR Code of Federal Regulations

CHIP Children's Health Insurance Program

CJR Comprehensive Care for Joint Replacement

CMHC Community Mental Health Center

CMI Case Mix Index

CMP Civil monetary penalty

CQMC Core Quality Measure Collaborative

CMS Centers for Medicare & Medicaid Services

CoP Condition of Participation

CORF Comprehensive Outpatient Rehabilitation Facility

CPC Comprehensive Primary Care Initiative

CPT Current Procedural Terminology

CR Cardiac rehabilitation

CRNA Certified Registered Nurse Anesthetists

CSA Combined Statistical Area

CVICU Cardiovascular intensive care units

CY Calendar year

DES Drug-eluting stents

DME Durable medical equipment

DMEPOS Durable medical equipment, prosthetics, orthotics, and supplies

DR Downside Risk

DSH Disproportionate Share Hospital

DUA Data Use Agreement

ED Emergency Department

ECMO Extracorporeal membrane circulation

ECQM Electronic Clinical Quality Measures

EFT Electronic funds transfer

EGM Episode Grouper for Medicare

EHR Electronic health record

E/M Evaluation and management

EPM Episode payment model

ESCO ESRD Seamless Care Organization

ESRD End-Stage Renal Disease

FFS Fee-for-service

FFR Fractional Flow Reserve

GAAP Generally-Accepted Accounting Principles

GEM General Equivalence Mapping

GPCI Geographic Practice Cost Index

HAC Hospital-Acquired Condition

HACRP Hospital-Acquired Condition Reduction Program

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems

HCC Hierarchical Condition Category

HCPCS Healthcare Common Procedure Coding System

HHA Home health agency

HHPPS Home Health Prospective Payment System

HHRG Home Health Resource Group

HHS U.S. Department of Health and Human Services

HH QRP Home Health Quality Reporting Program

HICN Health Insurance Claim Number

HIPAA Health Insurance Portability and Accountability Act

HIQR Hospital Inpatient Quality Reporting

HIV Human Immunodeficiency Virus

Health IT Health Information Technology

HLM Hierarchical Logistic Regression model

HLMR HCAHPS Linear Mean Roll Up

HOOS Hip Dysfunction and Osteoarthritis Outcome Score

HOPD Hospital outpatient department

HRRP Hospital Readmissions Reductions Program

HRR Hospital Referral Region

HVBP Hospital Value-Based Purchasing Program

ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification

ICHOM International Consortium for Health Outcomes Measurement

IRFQR Inpatient Rehabilitation Facilities Quality Reporting

ICD Implantable Cardioverter Defibrillator

ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification

ICR Intensive Cardiac Rehabilitation

I-I Inpatient to inpatient transfer

IME Indirect medical education

IP Inpatient

IPF Inpatient psychiatric facility

IPF QRP Inpatient Psychiatric Facility Quality Reporting Program

IPPS Inpatient Prospective Payment System

IRF Inpatient rehabilitation facility

IRF QRP Inpatient Rehabilitation Facility Quality Reporting Program

IVR Active Interactive Voice Recognition

KOOS Knee Injury and Osteoarthritis Outcome Score

LAN Healthcare Payment Learning and Action Network

LBBB Left bundled branch block

LEJR Lower-extremity joint replacement

LEP limited English proficiency

LIP Low-income percentage

LOS Length-of-stay

LTCH QRP Long-Term Care Hospital Quality Reporting Program

LTCH Long-term care hospital

LUPA Low-utilization payment adjustment

MA Medicare Advantage

MAC Medicare Administrative Contractor

MACRA Medicare Access and CHIP Reauthorization Act of 2015

MAP Measure Application Partnership

MAPCP Multi-Payer Advanced Primary Care Practice

MAT Measure Authoring Tool

MCC Major complications or comorbidities

MCCM Medicare Care Choices Model

MDC Major diagnostic category

MDH Medicare-Dependent Hospital

MDM Master Database Management

MedPAC Medicare Payment Advisory Commission

MIPS Merit-based Incentive Payment System

MP Malpractice

MSA Metropolitan Statistical Area

MS-DRG Medical Severity Diagnosis-Related Group

MSPB Medicare Spending Per Beneficiary

NHDS National Hospital Discharge Survey

NCDR National Cardiovascular Data Registry

NDR No Downside Risk

NPI National Provider Identifier

NPPGP Non-Physician Practitioner Group Practice

NPRA Net Payment Reconciliation Amount

NQF National Quality Forum

NSTEMI Non ST-elevation myocardial infarction

OCM Oncology Care Model

OIG Department of Health and Human Services' Office of the Inspector General

O-I Outpatient-to-inpatient transfer

OPPS Outpatient Prospective Payment System

OPT Outpatient Physical Therapist

OQR Outpatient Quality Reporting

PACE Program of All-Inclusive Care for the Elderly

PBPM Per-beneficiary per-month

PCI Percutaneous Coronary Intervention

PCMH Primary Care Medical Homes

PE Practice Expense

PEP Partial Episode Payment

PFS Physician Fee Schedule

PGP Physician group practice

PHA Partial hip arthroplasty

PQRS Physician Quality Reporting System

PPS Prospective Payment System

PRO Patient-Reported Outcome

PROMIS Patient-Reported Outcomes Measurement Information Systems

PROM Patient-Reported Outcome Performance Measure

PTAC Focused Payment Model Technical Advisory Committee

PTCA Percutaneous transluminal coronary angioplasty

PY Performance year

QCDR Qualified clinical data registries

QE Qualified Entity

QIO Quality Improvement Organization

QP Qualifying APM Participant

QPP Quality Payment Program

QRDA Quality Reporting Document Architecture

QRUR Quality and Resource Use Reports

RAC Recovery Audit Contractor

RRC Rural Referral Center

RSCR Risk-Standardized Complication Rate

RSRR Risk-Standardized Readmission Rate

RSMR Risk-Standardized Mortality Rate

RVU Relative Value Unit

SCH Sole Community Hospital

SDS Socio-demographic Status

SFT Secure File Transfer

SHFFT Surgical hip/femur fracture treatment

--This is a summary of a Federal Register article originally published on the page number listed below--

Final rule.

CFR Part: "42 CFR Parts 510 and 512"

RIN Number: "RIN 0938-AS90"

Citation: "82 FR 180"

Document Number: "CMS-5519-F"

Federal Register Page Number: "180"

"Rules and Regulations"