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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.