Comprehensive Care for Joint Replacement (CJR)

CJR is a CMS Innovation Center payment model originally launched in April 2016 and made mandatory in October 2021 for acute-care hospitals in selected metropolitan statistical areas. Under CJR, a single episode of care is triggered by an anchor event—either an inpatient admission assigned to MS-DRG 469 or 470, or a qualifying outpatient total hip or total knee arthroplasty procedure—and extends for 90 days following hospital discharge or the outpatient procedure date. The episode captures nearly all related Medicare Part A and Part B expenditures during that window, including post-acute care at skilled nursing facilities, inpatient rehabilitation facilities, home health agencies, and outpatient therapy.

At the end of each performance year, CMS reconciles each hospital's actual episode spending against a preestablished target price derived from a blend of the hospital's historical costs and regional averages. Hospitals that finish below the target while meeting quality benchmarks can receive a reconciliation payment; those that exceed the target may owe Medicare a repayment, subject to stop-loss limits. This structure creates a direct financial incentive for hospitals to coordinate care across surgeons, anesthesiologists, physical therapists, and post-acute providers rather than allowing fragmented, fee-for-service decisions to drive up total episode cost.

In April 2026, CMS proposed CJR-X (Comprehensive Care for Joint Replacement Expanded), which would reestablish and broaden the model on a nationwide basis, extending mandatory participation beyond the original metropolitan statistical areas and refining episode triggers to reflect contemporary care delivery—including the expanded use of outpatient settings for joint replacement. Coders and billing teams should monitor CJR-X rulemaking closely, as finalization would significantly expand the hospital universe subject to bundled-payment accountability.

Because the 90-day CJR episode budget is global, every downstream claim a hospital's network submits—SNF days, home health visits, readmissions, outpatient therapy—directly affects whether the hospital earns a reconciliation payment or owes a repayment to Medicare. A coder who incorrectly assigns MS-DRG 469 (with MCC) instead of MS-DRG 470 (without MCC) on the anchor hospitalization triggers a different target price, potentially understating or overstating expected spend and distorting the reconciliation calculation. Similarly, failing to apply the correct outpatient HCPCS anchor code for an outpatient TKA or THA means the episode may not open at all, leaving quality and cost data unattributed and exposing the hospital to audit risk under CMS oversight of the model.