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| Scope of Episodes Being Tested | 512.525 – 512.537 | ||||||||||
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42 U.S.C. 1302, 1315a, and 1395hh.
85 FR 61362, Sept. 29, 2020, unless otherwise noted.
89 FR 69914, Aug. 28, 2024, unless otherwise noted.
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Subscribe to: 42 CFR Part 512 Subpart E - Scope of Episodes Being Tested
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(a) Time periods. All episodes must begin on or after January 1, 2026 and end on or before December 31, 2030.
(b) Episode attribution. All items and services included in the episode are attributed to the TEAM participant at which the anchor hospitalization or anchor procedure, as applicable, occurs.
(c) Episode initiation. An episode is initiated by—
(1) A beneficiary's admission to a TEAM participant for an anchor hospitalization that is paid under a MS-DRG specified in paragraph (d) of this section; or
(2) A beneficiary's receipt of an anchor procedure billed under a HCPCS code specified in paragraph (d) of this section. If an anchor hospitalization is initiated on the same day as or in the 3 days following an outpatient procedure that could initiate an anchor procedure for the same episode category, the episode start date is that of the outpatient procedure rather than the admission date, and an anchor procedure is not initiated.
(d) Episode categories. The MS-DRGs and HCPCS codes included in the episodes are as follows:
(1) Lower Extremity Joint Replacement (LEJR):
(i) IPPS discharge under MS-DRG 469, 470, 521, or 522; or
(ii) OPPS claim for HCPCS codes 27447, 27130, or 27702.
(2) Surgical Hip/Femur Fracture Treatment (SHFFT). IPPS discharge under MS-DRG 480 to 482.
(3) Coronary Artery Bypass Graft Surgery (CABG). IPPS discharge under MS-DRG 231 to 236.
(4) Spinal Fusion:
(i) IPPS discharge under MS-DRG 402, 426, 427, 428, 429, 430, 447, 448, 450, 451, 471, 472, 473; or
(ii) OPPS claim for HCPCS codes 22551, 22554, 22612, 22630, or 22633.
(5) Major Bowel Procedure. IPPS discharge under MS-DRG 329 to 331.
(e) Included services. All Medicare Part A and B items and services are included in the episode, except as specified in paragraph (f) of this section. These services include, but are not limited to, the following:
(1) Physicians' services.
(2) Inpatient hospital services (including hospital readmissions).
(3) IPF services.
(4) LTCH services.
(5) IRF services.
(6) SNF services.
(7) HHA services.
(8) Hospital outpatient services.
(9) Outpatient therapy services.
(10) Clinical laboratory services.
(11) DME.
(12) Part B drugs and biologicals, except for those excluded under paragraph (f) of this section.
(13) Hospice services.
(14) Part B professional claims dated in the 3 days prior to an anchor hospitalization if a claim for the surgical procedure for the same episode category is not detected as part of the hospitalization because the procedure was performed by the TEAM participant on an outpatient basis, but the patient was subsequently admitted as an inpatient.
(f) Excluded services. The following items, services, and payments are excluded from the episode:
(1) Select items and services considered unrelated to the anchor hospitalization or the anchor procedure for episodes in the baseline period and performance year, including, but not limited to, the following:
(i) Inpatient hospital admissions for MS-DRGs that group to the following categories of diagnoses:
(A) Oncology.
(B) Trauma medical.
(C) Organ transplant.
(D) Ventricular shunt.
(ii) Inpatient hospital admissions that fall into the following Major Diagnostic Categories (MDCs):
(A) MDC 02 (Diseases and Disorders of the Eye).
(B) MDC 14 (Pregnancy, Childbirth, and Puerperium).
(C) MDC 15 (Newborns).
(D) MDC 25 (Human Immunodeficiency Virus).
(2) New technology add-on payments, as defined in part 412, subpart F of this chapter for episodes in the baseline period and performance year.
(3) Transitional pass-through payments for medical devices as defined in § 419.66 of this chapter for episodes initiated in the baseline period and performance year.
(4) Hemophilia clotting factors provided in accordance with § 412.115 of this chapter for episodes in the baseline period and performance year.
(5) Part B payments for low-volume drugs, high-cost drugs and biologicals, and blood clotting factors for hemophilia for episodes in the baseline period and performance year, billed on outpatient, carrier, and DME claims, defined as—
(i) Drug/biological HCPCS codes that are billed in fewer than 31 episodes in total across all episodes in TEAM during the baseline period;
(ii) Drug/biological HCPCS codes that are billed in at least 31 episodes in the baseline period and have a mean cost of greater than $25,000 per episode in the baseline period; and
(iii) HCPCS codes corresponding to clotting factors for hemophilia patients, identified in the quarterly average sales price file for certain Medicare Part B drugs and biologicals as HCPCS codes with clotting factor equal to 1, HCPCS codes for new hemophilia clotting factors not included in the baseline period, and other HCPCS codes identified as hemophilia.
(6) Part B payments for low-volume drugs, high-cost drugs and biologicals, and blood clotting factors for hemophilia for episodes initiated in the performance year, billed on outpatient, carrier, and DME claims, defined as—
(i) Drug/biological HCPCS codes that were not captured in the baseline period and appear in 10 or fewer episodes in the performance year;
(ii) Drug/biological HCPCS codes that were not included in the baseline period, appear in more than 10 episodes in the performance year, and have a mean cost of greater than $25,000 per episode in the performance year; and
(iii) Drug/biological HCPCS codes that were not included in the baseline period, appear in more than 10 episodes in the performance year, have a mean cost of $25,000 or less per episode in the performance year, and correspond to a drug/biological that appears in the baseline period but was assigned a new HCPCS code between the baseline period and the performance year.
(iv) HCPCS codes for new hemophilia clotting factors not included in the baseline period.
(g) TEAM exclusions List. The list of excluded MS-DRGs, MDCs, and HCPCS codes is posted on the CMS website.
(h) Updating the TEAM exclusions list. The list of excluded services is updated through rulemaking to reflect all of the following:
(1) Changes to the MS-DRGs under the IPPS.
(2) Coding changes.
(3) Other issues brought to CMS' attention.
(a) Episodes tested in TEAM include only those in which care is furnished to beneficiaries who meet all of the following criteria upon admission for an anchor procedure or anchor hospitalization:
(1) Are enrolled in Medicare Parts A and B.
(2) Are not eligible for Medicare on the basis of having end stage renal disease, as described in § 406.13 of this chapter.
(3) Are not enrolled in any managed care plan (for example, Medicare Advantage, health care prepayment plans, or cost-based health maintenance organizations).
(4) Are not covered under a United Mine Workers of America health care plan.
(5) Have Medicare as their primary payer.
(b) The episode is canceled in accordance with § 512.537(b) if at any time during the episode a beneficiary no longer meets all criteria in this section.
(a) Episode conclusion.
(1) An episode ends on the 30th day following the date of the anchor procedure or the date of discharge from the anchor hospitalization, as applicable, with the date of the anchor procedure or the date of discharge from the anchor hospitalization being counted as the first day in the 30-day post-discharge period.
(b) Cancellation of an episode. The episode is canceled and is not included in the reconciliation calculation as specified in § 512.545 if any of the following occur:
(1) The beneficiary ceases to meet any criterion listed in § 512.535.
(2) The beneficiary dies during the anchor hospitalization or the outpatient stay for the anchor procedure.
(3) The episode qualifies for cancellation due to extreme and uncontrollable circumstances. An extreme and uncontrollable circumstance occurs if both of the following criteria are met:
(i) The TEAM participant has a CCN primary address that—
(A) Is located in an emergency area, as those terms are defined in section 1135(g) of the Act, for which the Secretary has issued a waiver under section 1135 of the Act; and
(B) Is located in a county, parish, or tribal government designated in a major disaster declaration or emergency disaster declaration under the Stafford Act.
(ii) The date of admission to the anchor hospitalization or the date of the anchor procedure is during an emergency period (as defined in section 1135(g) of the Act) or in the 30 days before the date that the emergency period (as defined in section 1135(g) of the Act) begins.