Transcript Design Dimensions for a TJR Episode (continued)

Design Dimensions for a TJR Episode
Dimension
Description
I. Identify the episode
trigger
Each TJR episode is triggered by a surgical procedure for total hip replacement or total knee replacement. For
example, the following CPT procedure codes trigger a TJR episode:

27130 - Total hip arthroplasty

27447 - Total knee arthroplasty
Revision, replacement, and conversion procedures do not qualify as triggers. Further, a TJR with a diagnosis of a
fracture, internal injuries, intracranial or crushing injury is disqualified to be a trigger.
A trigger must be preceded and followed by a 90-day period clean of another trigger.
II. Determine the
episode duration
The duration of a TJR episode includes the “pre-trigger”, “trigger” and the “post-trigger” windows. See Figure 1
for an overview of the timing for a TJR episode.
The trigger window starts the day of admission for the trigger procedure and ends on the day of discharge from
that admission. The pre-trigger window starts 45 days prior to the day of admission for the trigger procedure
and ends on the day prior to that admission.
The post-trigger window begins the day after discharge and ends the 90th day post-discharge.
III. Identify included and The TJR episode gathers claims directly related to or stemming from a TJR procedure, including inpatient, ED,
excluded claims
outpatient, professional, and pharmacy claims. As shown in Figure 2, the logic used to identify included and
excluded claims differs by episode window.
All claims during the trigger period are included in the episode. During the pre-trigger window, all related claims
and all claims filed by the Quarterback (with some exceptions) are included. No medications are included.
The post-trigger period uses two windows. The first window spans the first 30 days following the trigger
window and includes all non-excluded inpatient or ED admissions and the services that are delivered to the
patient during those admissions. During the second post-trigger window (31 to 90 days follow the trigger
window) all related medical claims and related medications are included.
Excluded admissions and ED events are defined using procedure codes. Related medical and pharmacy claims
are defined using both included diagnosis codes and excluded procedure codes.
IV. Calculate total
episode cost
The total episode cost is the sum of the amount that reflects the totality of costs for all claims included in the
episode (hospital, physician, ancillary and drug).
Design Dimensions for a TJR Episode (continued)
Dimension
Description
V. Identify the
Quarterback
The Quarterback of the episode is the provider deemed to have the greatest accountability for the quality and
cost of care delivered. For a TJR episode, the Quarterback is the tax id of the billing provider (or group) of the
TJR procedure.
Episode exclusions ensure that the remaining episodes are comparable to each other and allow fair
comparisons between providers. The exclusions applied for TJR episodes are:
VI. Identify episodes to
be excluded

Age: Episodes with patients older than 64 years

Comorbidities: Patient has a diagnosis or procedure indicating a significant comorbidity, such as: HIV
infection, ESRD, pregnancy, organ transplantation, sickle cell, blindness, hemophilia, active cancer and
trauma Comorbidities are identified during the episode period or the prior year.

General exclusions: An episode can be excluded based on non-clinical criteria, including: the presence of
dual primary insurance coverage; the patient dies in the hospital or leaves the hospital against medical
advice during the episode; evidence of incomplete claims; or a high cost outlier (total episode costs are
above a high-cost outlier threshold).
VII. Identify
Quarterbacks who meet
the quality metrics
A Quarterback must meet a specified set of quality metrics in order to be eligible for gain sharing. Quality
metrics are calculated across all episodes for a Quarterback. Failure to meet all of these quality metrics will
eliminate a Quarterback from gain sharing for the performance period in question. For TJR, the quality metrics
tied to gain-sharing include:

30 day all-cause readmission rate.
VIII. Perform risk
adjustment
For the purposes of determining performance, the average cost of episodes attributable to a Quarterback is
adjusted to reflect risk factors observed for episode patients. Risk adjustment is designed to promote fair
comparisons across providers and to avoid any incentive for adverse selection of patients. Episode risk is
based on patient TJR-related risk factors and comorbidities. The cost for an episode divided by the risk score
for the episode to determine risk adjusted episode cost. Average risk adjusted episode cost is compared with
thresholds to determine any gain-sharing.