§ 512.2 - Definitions.

§ 512.2 Definitions.

For the purposes of this part, the following definitions are applicable unless otherwise stated:

ACO means an accountable care organization, as defined at § 425.20 of this chapter, that participates in the Shared Savings Program and is not in Track 3.

ACO participant has the meaning set forth in § 425.20 of this chapter.

ACO provider/supplier has the meaning set forth in § 425.20 of this chapter.

Actual episode payment means the sum of Medicare claims payments and certain non-claims-based payments for items and services that are included in the episode in accordance with § 512.210(a), excluding the items and services described in § 512.210(b).

Alignment payment means a payment from an EPM collaborator to an EPM participant under a sharing arrangement, for the sole purpose of sharing the EPM participant's responsibility for making repayments to Medicare.

AMI means acute myocardial infarction, an event caused by diminished blood supply to the heart leading to irreversible heart muscle cell damage or death.

AMI care period means a period of AMI care that would meet the requirements to be an AMI model episode in accordance with all provisions in subpart B of this part if the FFS-CR participant were an AMI model participant.

AMI model means the EPM for AMI.

AMI model participant means an EPM participant that is an IPPS hospital (other than those hospitals specifically excepted under § 512.100(b)) with a CCN primary address in one of the geographic areas selected for participation in the AMI model in accordance with § 512.105(b), as of the date of selection or any time thereafter during any performance year.

Anchor hospitalization means a hospitalization that initiates an EPM episode.

Anchor hospitalization portion means the part of an EPM episode that occurs during the anchor hospitalization.

Anchor MS-DRG means the MS-DRG assigned to the hospitalization discharge, which initiates an EPM episode.

Applicable discount factor means the discount percentage established by the EPM participant's quality category as determined in § 512.315, that is applied to the episode benchmark price for purposes of determining an EPM participant's Medicare repayment in performance year 2 for EPM participants who elect early downside risk and performance years 3 and 4 for all EPM participants.

Area means, as defined in § 400.200 of this chapter, the geographical area within the boundaries of a State, or a State or other jurisdiction, designated as constituting an area with respect to which a Professional Standards Review Organization or a Utilization and Quality Control Peer Review Organization has been or may be designated.

BPCI stands for the Bundled Payment for Care Improvement initiative.

CABG means coronary artery bypass graft, a surgical procedure that diverts the flow of blood around a section of a blocked or partially blocked artery in the heart, creating a new pathway that improves blood flow to heart muscle.

CABG care period means a period of CABG care that would meet the requirements to be a CABG model episode in accordance with all provisions in subpart B of this part if the FFS-CR participant were a CABG model participant.

CABG model means the EPM for CABG.

CABG model participant means an EPM participant that is an IPPS hospital (other than those hospitals specifically excepted under § 512.100(b)) with a CCN primary address in one of the geographic areas selected for participation in the CABG model in accordance with § 512.105(b), as of the date of selection or any time thereafter during any performance year.

CAH means a critical access hospital designated under subpart F of part 485 of this chapter.

CCN stands for CMS certification number.

CEC stands for Comprehensive ESRD Care Model.

CEHRT means certified electronic health record technology that meet the requirements of 45 CFR 170.102.

Collaboration agent means an individual or entity that is not an EPM collaborator and that is either of the following:

(1) A PGP member, an NPPGP member, or a TGP member that has entered into a distribution arrangement with the same PGP, NPPGP, or TGP in which he or she is an owner or employee, and where the PGP, NPPGP, or TGP is an EPM collaborator.

(2) An ACO participant or ACO provider/supplier that has entered into a distribution arrangement with the same ACO in which it is participating, and where the ACO is an EPM collaborator.

Core-based statistical area (CBSA) means a statistical geographic entity consisting of the county or counties associated with at least one core (urbanized area or urban cluster) of at least 10,000 population, plus adjacent counties having a high degree of social and economic integration with the core as measured through commuting ties with the counties containing the core.

CORF stands for comprehensive outpatient rehabilitation facility.

CR means cardiac rehabilitation as defined in § 410.49(a) of this chapter, a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcomes assessment.

CR amount means the dollar amount determined by the number of CR/ICR services paid by Medicare under the OPPS or to any supplier reporting place of service code 11 on the PFS claim for a beneficiary in an AMI or CABG model episode or AMI care period or CABG care period.

CR incentive payment means a payment made by CMS to an EPM-CR participant or FFS-CR participant for CR/ICR service use that is the sum of the CR amounts as determined in accordance with § 512.710.

CR incentive payment model means the model testing CR incentive payments for CR/ICR service use made in accordance with subpart H of this part.

CR participant means all EPM-CR participants and FFS-CR participants.

CR performance year means one of the years in which the CR incentive payment model is being tested. Performance years for the CR incentive payment model correlate to calendar years with the exception of performance year 1, which is July 1, 2017 through December 31, 2017.

CR service count means the number of CR/ICR services paid by Medicare under the OPPS or to any supplier reporting place of service code 11 on the PFS claim for a beneficiary in an AMI or CABG model episode or AMI care period or CABG care period.

Distribution arrangement means a financial arrangement between an EPM collaborator that is an ACO, PGP, NPPGP, or TGP and a collaboration agent for the sole purpose of distributing some or all of a gainsharing payment received by the ACO, PGP, NPPGP, or TGP.

Distribution payment means a payment from an EPM collaborator that is an ACO, PGP, NPPGP, or TGP to a collaboration agent, under a distribution arrangement, composed only of gainsharing payments.

DME stands for durable medical equipment.

Downstream collaboration agent means an individual who is not an EPM collaborator or a collaboration agent and who is a PGP member, an NPPGP member, or a TGP member that has entered into a downstream distribution arrangement with the same PGP, NPPGP, or TGP in which he or she is an owner or employee, and where the PGP, NPPGP, or TGP is a collaboration agent.

Downstream distribution arrangement means a financial arrangement between a collaboration agent that is both a PGP, NPPGP, or TGP and an ACO participant and a downstream collaboration agent for the sole purpose of distributing some or all of a distribution payment received by the PGP, NPPGP, or TGP.

Downstream distribution payment means a payment from a collaboration agent that is both a PGP, NPPGP, or TGP and an ACO participant to a downstream collaboration agent, under a downstream distribution arrangement, composed only of distribution payments.

Effective discount factor means the discount factor established by the EPM participant's quality category as determined in § 512.315, that is applied to the episode benchmark price to calculate the quality-adjusted target price.

Episode attribution means the process of assigning financial responsibility for an EPM episode to an EPM participant.

Episode benchmark price means a dollar amount assigned to EPM episodes based on historical episode data (3 years of historical Medicare payment data grouped into EPM episodes according to the EPM episode definitions as discussed in § 512.300(b)) prior to the application of the effective discount factor, as described in § 512.300(d).

Episode payment model (EPM) means the AMI model, CABG model, SHFFT model, or another model with payment made on an episode basis in accordance with this part. Each section of the regulations applies in its entirety to each model.

EPM activities means activities related to promoting accountability for the quality, cost, and overall care for EPM beneficiaries, including managing and coordinating care; encouraging investment in infrastructure, enabling technologies, and redesigned care processes for high quality and efficient service delivery; the provision of items and services during an EPM episode in a manner that reduces costs and improves quality; or carrying out any other obligation or duty under the EPM.

EPM beneficiary means a beneficiary who meets the beneficiary inclusion criteria in § 512.230 and who is in an EPM episode.

EPM collaborator means an ACO or one of the following Medicare-enrolled individuals or entities that enters into a sharing arrangement:

(1) SNF.

(2) HHA.

(3) LTCH.

(4) IRF.

(5) Physician.

(6) Nonphysician practitioner.

(7) Therapist in private practice.

(8) CORF.

(9) Provider of outpatient therapy services.

(10) PGP.

(11) Hospital.

(12) CAH.

(13) NPPGP.

(14) TGP.

EPM composite quality score means a score computed for each EPM participant's level of quality performance and improvement and successful reporting of voluntary data, if applicable, on specified EPM quality measures as described in § 512.315.

EPM-CR participant means an AMI or CABG model participant that is eligible to receive CR incentive payments from CMS in accordance with § 512.710.

EPM episode of care (or Episode) means all Medicare Part A and Part B items and services described in § 512.210(a) (and excluding the items and services described in § 512.210(b)) that are furnished to an EPM beneficiary described in § 512.240 that begins with the beneficiary's admission to an anchor hospitalization, with the day of discharge itself from the anchor hospitalization being counted as the first day of the 90-day post-discharge period.

EPM participant means a Medicare provider or supplier that is eligible to receive payment from CMS on an episode basis for services rendered to EPM beneficiaries.

EPM volume protection hospital means an EPM participant that meets the requirements under § 512.305(c)(2)(iii)(D).

ESRD stands for end-stage renal disease.

FFS-CR beneficiary means a beneficiary attributed to an FFS-CR participant and receiving care during an AMI care period or CABG care period.

FFS-CR participant means a hospital that is not an EPM participant and that is eligible to receive CR incentive payments from CMS in accordance with § 512.710.

Gainsharing payment means a payment from an EPM participant to an EPM collaborator, under a sharing arrangement, composed of only reconciliation payments or internal cost savings or both.

HCAHPS stands for Hospital Consumer Assessment of Healthcare Providers and Systems.

HCPCS stands for CMS Common Procedure Coding System.

Health Insurance Claim Number (HICN) means the unique number assigned by the Social Security Administration to an individual for the purpose of identifying that individual as a Medicare beneficiary.

HHA means a Medicare-enrolled home health agency.

Historical episode payment means the expenditures for episodes that occurred during the historical period used to determine the EPM episode benchmark price.

Hospital means a provider subject to the prospective payment system specified in § 412.1(a)(1) of this chapter.

ICD-CM stands for International Classification of Diseases, Clinical Modification.

ICR means intensive cardiac rehabilitation as defined in § 410.49(a) of this chapter, a physician-supervised program that furnishes cardiac rehabilitation and has shown, in peer-reviewed published research, that it improves patients' cardiovascular disease through specific outcome measurements described in § 410.49(c) of this chapter.

Inpatient prospective payment systems (IPPS) means the payment systems for subsection (d) hospitals as defined in section 1886(d)(1)(B) of the Act.

Internal cost savings means the measurable, actual, and verifiable cost savings realized by the EPM participant resulting from care redesign undertaken by such participant in connection with providing items and services to beneficiaries within specific EPM episodes. Internal cost savings does not include savings realized by any individual or entity that is not the EPM participant.

Intracardiac procedures means procedures performed within the heart chambers, rather than within coronary artery blood vessels, through percutaneous access to blood vessels. These procedures are indicated for the treatment of congenital cardiac malformations, cardiac valve disease, and cardiac arrhythmias.

IPF stands for inpatient psychiatric facility.

IRF stands for inpatient rehabilitation facility.

LTCH stands for long-term care hospital.

MDH means a Medicare-dependent, small rural hospital that meets the classification criteria specified under § 412.108 of this chapter.

Member of the PGP or PGP member means a physician, nonphysician practitioner, or therapist who is an owner or employee of a PGP and who has reassigned to the PGP his or her right to receive Medicare payment.

Member of the NPPGP or NPPGP member means a nonphysician practitioner or therapist who is an owner or employee of an NPPGP and who has reassigned to the NPPGP his or her right to receive Medicare payment.

Member of the TGP or TGP member means a therapist who is an owner or employee of a TGP and who has reassigned to the TGP his or her right to receive Medicare payment.

MSA stands for metropolitan statistical area and means a CBSA associated with at least one urbanized area that has a population of at least 50,000.

MS-DRG stands for Medicare severity diagnosis-related group, which is the classification of inpatient hospital discharges updated in accordance with § 412.10 of this chapter.

Nonphysician practitioner means (except for purposes of subpart G of this part) one of the following:

(1) A physician assistant who satisfies the qualifications set forth at § 410.74(a)(2)(i) and (ii) of this chapter.

(2) A nurse practitioner who satisfies the qualifications set forth at § 410.75(b) of this chapter.

(3) A clinical nurse specialist who satisfies the qualifications set forth at § 410.76(b) of this chapter.

(4) A certified registered nurse anesthetist (as defined at § 410.69(b) of this chapter).

(5) A clinical social worker (as defined at § 410.73(a) of this chapter).

(6) A registered dietician or nutrition professional (as defined at § 410.134 of this chapter).

NPI stands for National Provider Identifier.

NPPGP means an entity that is enrolled in Medicare as a group practice, includes at least one owner or employee who is a nonphysician practitioner, does not include a physician owner or employee, and has a valid and active TIN.

NPRA means the net payment reconciliation amount determined in accordance with § 512.305(c).

OIG stands for the Department of Health and Human Services Office of Inspector General.

OPPS stands for the Medicare Outpatient Prospective Payment System.

PAC stands for post-acute care.

PBPM stands for per-beneficiary-per-month.

PCI means percutaneous coronary intervention, a procedure used to open blocked arteries in the heart through percutaneous placement of a small wire mesh tube that keeps the artery open and minimizes the risk of it later narrowing.

Performance year means one of the years in which the EPM is being tested. Performance years for the EPMs correlate to calendar years with the exception of performance year 1, which is July 1, 2017 through December 31, 2017.

PFS means the Medicare Physician Fee Schedule authorized under section 1848 of the Act.

PGP stands for physician group practice.

Physician has the meaning set forth in section 1861(r) of the Act.

Post-anchor hospitalization portion means the part of an episode that occurs after the anchor hospitalization.

Post-episode spending amount means the sum of Medicare Parts A and B payments for items and services that are furnished to a beneficiary within 30 days after the end of the beneficiary's EPM episode.

Provider of outpatient therapy services means an entity that is enrolled in Medicare as a provider of therapy services and furnishes one or more of the following:

(1) Outpatient physical therapy services as defined in § 410.60 of this chapter.

(2) Outpatient occupational therapy services as defined in § 410.59 of this chapter.

(3) Outpatient speech-language pathology services as defined in § 410.62 of this chapter.

Quality-adjusted target price means the dollar amount assigned to EPM episodes as the result of reducing the episode benchmark price by the EPM participant's effective discount factor based on the EPM participant's quality category, as described in § 512.315(b)(5), (c)(5), or (d)(5).

Quality improvement points are points that CMS adds to an EPM participant's EPM composite quality score for a measure if the EPM participant's performance improves from the previous performance year according to the relevant EPM measure improvement methodology.

Quality performance points are points that CMS adds to an EPM participant's EPM composite quality score for a measure based on the performance percentile scale and for successful submission of voluntary data if applicable to the EPM.

Reconciliation payment means a payment made by CMS to an EPM participant as determined in accordance with § 512.305(d).

Repayment amount means the amount owed by an EPM participant to CMS, as reflected on a reconciliation report.

RRC means a rural referral center that satisfies the criteria set forth in § 412.96 of this chapter.

Rural hospital means an IPPS hospital that meets one of the following definitions:

(1) Is located in a rural area as defined under § 412.64 of this chapter.

(2) Is located in a rural census tract defined under § 412.103(a)(1) of this chapter.

(3) Has reclassified as a rural hospital under § 412.103 of this chapter.

SCH means a sole community hospital that meets the classification criteria specified in § 412.92 of this chapter.

Sharing arrangement means a financial arrangement between an EPM participant and an EPM collaborator for the sole purpose of making gainsharing payments or alignment payments under the EPM.

SHFFT stands for surgical hip/femur fracture treatment and means surgical treatment for hip and femur fractures, other than hip replacements, consisting primarily of hip fixation procedures, with or without reduction of the fracture, as well as open and closed surgical approaches.

SHFFT model means the EPM for SHFFT.

SHFFT model participant means an EPM participant that is an IPPS hospital (other than those hospitals specifically excepted under § 512.100(b)) with a CCN primary address in one of the geographic areas selected for participation in a SHFFT model in accordance with § 512.105(a), as of the date of selection or any time thereafter during any performance year.

SNF stands for skilled nursing facility.

TGP means an entity that is enrolled in Medicare as a therapy group in private practice, includes at least one owner or employee who is a therapist in private practice, does not include an owner or employee who is a physician or nonphysician practitioner, and has a valid and active TIN.

THA/TKA stands for total hip arthroplasty/total knee arthroplasty.

Therapist means one of the following individuals as defined at § 484.4 of this chapter:

(1) Physical therapist.

(2) Occupational therapist.

(3) Speech-language pathologist.

Therapist in private practice means a therapist that either -

(1) Complies with the special provisions for services furnished by physical therapists in private practice in § 410.60(c) of this chapter;

(2) Complies with the special provisions for services furnished by occupational therapists in private practice in § 410.59(c) of this chapter; or

(3) Complies with the special provisions for services furnished by speech-language pathologists in private practice in § 410.62(c) of this chapter.

TIN stands for taxpayer identification number.

Two-sided risk arrangement means an arrangement in which the ACO may share savings with the Medicare program, if it meets the requirements for doing so, and is also liable for sharing losses incurred under the program or model, if it meets the criteria under which sharing losses occurs.