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Federal Register / Vol. 86, No. 83 / Monday, May 3, 2021 / Rules and Regulations 4 For performance years 1 through 5
only, CMS posts the following to the CMS website:

5 For performance years 6 through 8, the list of excluded services posted on the CMS website as it appears at the beginning of performance year 5 will apply and will not be updated.
7. Section 510.205 is amended by revising paragraph a6iii to read as follows:
510.205

Beneficiary inclusion criteria.

a
6
iii A Shared Savings Program ACO
in the ENHANCED track formerly Track 3.

8. Section 510.210 is amended by revising paragraphs a and b1ii to read as follows:

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510.210

Determination of the episode.

a General. 1 An episode begins with the admission of a Medicare beneficiary described in 510.205 to a participant hospital for an anchor hospitalization and ends on the 90th day after the date of discharge, with the day of discharge itself being counted as the first day in the 90-day postdischarge period.
2 On or after July 4, 2021, an episode i Begins and ends in the manner specified in paragraph a1 of this section; or ii Begins on the date of service of an anchor procedure furnished to a Medicare beneficiary described in 510.205 and ends on the 90th day after the date of service of the anchor procedure.
b
1
ii Is readmitted to any participant hospital for another anchor hospitalization, or, on or after July 4, 2021, receives an anchor procedure at any participant hospital.

9. Section 510.300 is amended by a. Revising paragraph a2 through a4;
b. Adding paragraphs a6, and b1iv through vi; and c. Revising paragraphs b2iii, b5, and c3iii.
The revisions and additions read as follows:
510.300 Determination of episode quality-adjusted target prices.

a
2 Applicable time period for performance year or performance year
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subset episode quality-adjusted target prices. For performance years 1 through 4 and performance year subset 5.1 only, episode quality-adjusted target prices are updated to account for Medicare payment updates no less than 2 times per year, for updated quality-adjusted target prices effective October 1 and January 1, and at other intervals if necessary.
3 Episodes that straddle performance years, performance year subsets, or payment updates. The quality-adjusted target price that applies to the episode is one of the following:
i For episodes beginning on or after April 1, 2016 and ending on or before September 30, 2021, the date of admission for the anchor hospitalization.
ii For episodes beginning on or after July 4, 2021 and ending on or after October 1, 2021, the date of the anchor procedure or the date of admission for the anchor hospitalization, as applicable.
4 Identifying episodes with hip fracture. CMS develops a list of ICDCM
hip fracture diagnosis codes that, when reported in the principal diagnosis code files on the claim for the anchor hospitalization or anchor procedure, represent a bone fracture for which a hip replacement procedure, either a partial hip arthroplasty or a total hip arthroplasty, could be the primary surgical treatment. The list of ICDCM
hip fracture diagnosis codes used to identify hip fracture episodes can be found on the CMS website. Beginning on October 1, 2020, hip fracture episodes initiated by an anchor hospitalization will be identified by MSDRGs 521 and 522.
i For performance years 1 through 5
only, on an annual basis, or more frequently as needed, CMS updates the list of ICDCM hip fracture diagnosis codes to reflect coding changes or other issues brought to CMS attention.
ii For performance years 1 through 5 only, CMS applies the following standards when revising the list of ICD
CM hip fracture diagnosis codes.
A The ICDCM diagnosis code is sufficiently specific that it represents a bone fracture for which a physician could determine that a hip replacement procedure, either a Partial Hip Arthroplasty PHA or a THA, could be the primary surgical treatment.
B The ICDCM diagnosis code is the primary reason that is, principal diagnosis code for the anchor hospitalization.
iii For performance years 1 through 5 only, CMS posts the following to the CMS website:

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A Potential ICDCM hip fracture diagnosis codes for public comment;
and B A final ICDCM hip fracture diagnosis code list after consideration of public comment.
iv For performance years 6 through 8, the hip fracture diagnosis code list posted at https innovation.cms.gov/
Files/worksheets/cjricd10hipfracturecodes.xlsx as it appears at the beginning of performance year 5
will not be updated. The hip fracture diagnosis code list will be used to identify hip fracture episodes initiated by an anchor procedure in performance years 6 through 8.

6 For episodes beginning on or after July 4, 2021 that are initiated by an anchor procedure, permitted OP TKAs and OP THAs are grouped with MSDRG 470 or MSDRG 522 episodes as follows:
i Permitted OP THAs with hip fracture group with MSDRG 522.
ii Permitted OP THAs without hip fracture and permitted OP TKAs group with MSDRG 470.
b
1
iv Episodes beginning in 2019 for performance year 6.
v Episodes beginning in 2021 for performance year 7.
vi Episodes beginning in 2022 for performance year 8.
2
iii Regional historical episode payments for performance year 4, for each subset of performance year 5, and performance years 6 through 8.

5 Exception for high episode spending. i For performance years 1
through 4, and for performance year 5, each subset thereof, episode payments are capped at 2 standard deviations above the mean regional episode payment for both the hospital-specific and regional components of the qualityadjusted target price.
ii For performance years 6 through 8, episode payments are capped at the 99th percentile of regional spending for each of the four MSDRG categories, as specified in 510.300a1 and 6.

c
3
iii In performance years 4, each subset of performance year 5, and performance years 6 through 8, 3.0
percent.

10. Section 510.301 is added to read as follows:

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