CJR Reconciliation: Performance Year 1

Table 1 provides an overview of the inputs used to calculate your hospital’s reconciliation payment. Note that eligibility for reconciliation is based on compliance with CJR regulations, having an acceptable, good, or excellent composite quality score, and having a positive reconciliation amount. You can find this information in the RECON_AMT file in the Reports download on the CJR/EPM Data Portal.

Table 2 provides an overview of reconciliation episode spending and target prices by MS-DRG fracture combination for PY1. You can get all of the information from Table 2 in the HOSP_RECON_SUM available in the Reports download on the CJR/EPM data portal. In Table 2, the difference between target and actual spending is listed as the net payment reconciliation amount (NPRA). However, please note that reconciliation amounts are based on quality performance, post-episode spending, and stop-gain limits at the hospital level. For more information on how reconciliation amounts are calculated, please refer to the Reconciliation Specifications document available in the ReadMe download on the CJR/EPM Data Portal.

Table 3 shows results for your hospital’s quality measures in PY1. For more detailed results, including those during the baseline period, please refer to the QM file available in the Reports download on the CJR/EPM Data Portal.

Table 4 shows your hospital’s overall performance on quality measures and the PRO voluntary data submission for PY1. For more detailed results, including those in the baseline period, please refer to the QM file available in the Reports download on the CJR/EPM data portal.

Performance points were assigned according to the table below.

CMS assigns hospitals without reportable quality measure values to the 50th Percentile for the performance period. Hospitals without quality measures values are often low-volume participant hospitals. Low-volume hospitals for the Complications measure do not meet the minimum case count of 25 cases in the 3 year measurement period. Low-volume hospitals for the HCAHPS Survey measure do not meet the minimum 100 completed surveys in a 4 quarter period.

CMS adds quality improvement points to each hospital’s THA/TKA Complications measure and/or HCAHPS Survey measure quality performance points total if the hospital improves by three deciles or more on each measure's performance percentile scale. Improvement points are equal to 10 percent of the total available points for that individual measure.

Hospitals that successfully submit THA/TKA PRO and risk variable data receive two extra points toward their composite quality score. Hospitals that do not successfully submit THA/TKA PRO and risk variable data will receive no extra points.

The correspondence of composite quality scores to discount factors is shown below.

The CE form included in this reconciliation report package must be used by CJR participant hospitals to appeal matters related to reconciliation, payment, repayment, or determinations associated with quality measures that affect payment. Calculation errors may fall into the following categories:

1. Inclusion or exclusion of Medicare beneficiaries/episodes in the baseline or performance period;
2. Inclusion or exclusion of specific claims within episode spending in the baseline or performance period;
3. Reconciliation amount calculations (including payment adjustment factors used in calculation computations); and
4. Application or use of composite quality score during reconciliation or in determining the performance decile.

CJR participant hospitals have 45 calendar days from this report's issuing date to provide written notice of a calculation error to CMS. Please note that CMS will only accept CE forms from participant hospitals (42 CFR §510.310); appeals submitted by hospitals’ consultants or contractors will not be accepted. Unless CMS receives a hospital’s written notice of calculation error as outlined below, the CJR reconciliation report will be deemed final 45 calendar days after issuance. CMS will provide a written response to the participant hospital’s CE form within 30 calendar days of its receipt. CMS reserves the right to extend this 30 calendar day period upon written notice to the participant.

Please remember that in some instances participant hospitals may be unable to exactly replicate episode spending amounts, because, under current law, we are not permitted to provide Substance Abuse and Mental Health Services Administration (SAMHSA) claim-level information in participant hospital claims files. Per CMS policy, SAMHSA claim totals, while included in episode totals, are not provided in your claim-level files.

The CE form is included in the Reports download on the CJR/EPM Data Portal. The types of calculation errors are outlined on the top of the CE form. Each error type has a corresponding table within the CE form. Please only complete the tables that are applicable to your review request.

1. CJR participants can list multiple calculation errors on one form for a single CCN.
   1. Do not include calculation errors for multiple CCNs on one CE form.
2. Required fields in each table are marked with an asterisk (*).
3. If the error is related to the baseline period, please provide the date stamp (i.e., the date CMS created the file) on the historical data file.
   1. To find this date, right-click the unopened file and select "properties." A properties window will pop up with the created, modified, and accessed dates. Please record the created date.
   2. To ensure you are reviewing the most current version, compare the file's created date with the date of the historical file in the CJR/EPM Data Portal.
4. For calculation errors type (1) and (2), i.e. beneficiary, episode or claim related errors, please do not send any additional data apart from the data listed below:

   Data field	Definition
   Designation of baseline or performance year 1 error	Whether error is in the baseline or performance year 1 files.
   Date stamp	Date indicating when the file was created.
   CCN	Anchor hospital CMS Certification Number (uniquely identifies provider).
   EPI_ID	Key to uniquely identify CJR episodes.
   GEO_BENE_SK	IDR system variable - 4-part-key to identify a claim.
   CLM_DT_SGNTR_SK	IDR system variable - 4-part-key to identify a claim.
   CLM_TYPE_CD	IDR system variable - 4-part-key to identify a claim.
   CLM_NUM_SK	IDR system variable - 4-part-key to identify a claim.
   DROPREASON	Reason code why anchor stay is dropped. Listed in the EPIEXC file.
   EXCLUSION_CODE	Reason why a claim's payment was excluded from the episode total. Listed in the claim file.

   None of the variables we request contain personally identifiable information (PII) or protected health information (PHI). For more information on the variables listed above, please see the CJR Data Dictionary and File Layouts available on the CJR/EPM Data Portal.
5. Complete the calculation error type (3) table if the error relates to computation of the reconciliation payment amount. The only columns in this table that are required are (1) the notes column to explain the calculation error and/or to state the adjustment factor you believe should have been used (e.g., the wage index value) if you believe an incorrect factor was used, and (2) the target price episode period for which the wage factor applies (only applicable to wage factor errors). The other data elements listed in the table are optional.
6. Complete the calculation error type (4) table if the error relates to the composite quality score or its components. The only column in this table that is required is the notes column to explain the error. The other data elements listed in the table are optional.

1. Once the CE form has been completed, you must email the workbook to the CMS Appeals team (CJRreconciliation@cms.hhs.gov) within 45 calendar days of this reconciliation report’s issuance. The subject line of this email should contain (1) your hospital’s CMS Certification Number (CCN) and (2) "CE Review Request." This email must come directly from the participant hospital and not from a third party. Do not include any PII or PHI on the CE form or in the email (see list below for detailed list of PII and PHI).
2. Upon CMS’s receipt of your email workbook, you will receive an auto-reply from the CJR Reconciliation email box indicating your email was successfully submitted.
3. CMS will respond to your CE review request within 30 calendar days of its receipt, unless you are otherwise notified. If you would like additional individuals to receive CMS’s response, please carbon copy those individuals on the submission email.

PII and PHI Data Elements

The following data, often used for the express purpose of distinguishing individual identity, is classified as PII (under the definition used by the National Institute of Standards and Technology) and/or PHI (under the U.S. Health Insurance Portability and Accountability Act (HIPAA)).

• Full name, first or last name;
• Home address to include Country, state, postal code, or city of residence;
• Email addresses (if private from an association/club membership, etc.);
• National identification number, including Social Security Numbers;
• Passport number;
• Medical Record Numbers;
• Health insurance beneficiary numbers;
• Age, especially if non-specific;
• Date of birth;
• Birthplace;
• Gender or race;
• Genetic information;
• Telephone numbers and Fax Numbers;
• Vehicle registration plate number;
• Driver’s license number;
• Full face photographic images and any comparable images;
• Device identifiers and serial numbers;
• Biometric identifiers, including finger, retinal, and voice prints;
• Credit card numbers;
• Name of school they attend or workplace;
• Grades, salary, or job position;
• Criminal records;
• Account numbers;
• Certificate/license numbers;
• Digital identifiers;
• Login name, screen name, nickname, or handle;
• Web Uniform Resource Locators (URLs);
• Internet Protocol (IP) address numbers;
• IP address (when linked, but not PII by itself);
• Web cookie; and
• Any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data.