Section 512.540 - [Effective 10/1/2024] Determination of preliminary target prices(a)Preliminary target price application. CMS establishes preliminary target prices for TEAM participants for each performance year of the model as follows: (1)MS-DRG/HCPCS episode type. CMS uses the MS-DRGs and, as applicable, HCPCS codes specified in § 512.525(d) when calculating the preliminary target prices for each MS-DRG/HCPCS episode type.(i) CMS determines a separate preliminary target price for each of the 24 MS-DRGs specified in § 512.525(d).(ii) Preliminary target prices for a subset of the MS-DRGs specified in § 512.525(d) include certain HCPCS codes as follows:(A) HCPCS 27130 and 27447 are included in MS-DRG 470.(B) HCPCS 27702 is included in MS-DRG 469.(C) HCPCS 22551 and 22554 are included in MS-DRG 473.(D) HCPCS 22612 and 22630 are included in MS-DRG 451.(E) HCPCS 22633 is included in MS-DRG 402.(2)Applicable time period for preliminary target prices. CMS calculates preliminary target prices for each MS-DRG/HCPCS episode type and region for each performance year and applies the preliminary target price to each episode based on the episode's date of discharge from the anchor hospitalization or the episode's date of the anchor procedure, as applicable.(3)Episodes that begin in one performance year and end in the subsequent performance year. CMS applies the preliminary target price to the episode based on the date of discharge from the anchor hospitalization or the date of the anchor procedure, as applicable, but reconciles the episode based on the end date of the episode.(b)Preliminary target price calculation.(1) CMS calculates preliminary target prices based on average baseline episode spending for the region where the TEAM participant is located.(i) The region used for calculating the preliminary target price corresponds to the U.S. Census Division associated with the primary address of the CCN of the TEAM participant, and the regional episode spending amount is based on all hospitals in the region, except as specified in § 512.540(b)(1)(ii).(ii) In cases where a TEAM participant is located in a mandatory CBSA selected for participation in TEAM which spans more than one region, the TEAM participant and all other hospitals in the mandatory CBSA are grouped into the region where the most populous city in the mandatory CBSA is located for pricing and payment calculations.(2) CMS uses the following baseline periods to determine baseline episode spending:(i) Performance Year 1: Episodes beginning on January 1, 2022 through December 31, 2024.(ii) Performance Year 2: Episodes beginning on January 1, 2023 through December 31, 2025.(iii) Performance Year 3: Episodes beginning on January 1, 2024 through December 31, 2026.(iv) Performance Year 4: Episodes beginning on January 1, 2025 through December 31, 2027.(v) Performance Year 5: Episodes beginning on January 1, 2026 through December 31, 2028.(3) CMS calculates the benchmark price as the weighted average of baseline episode spending, applying the following weights: (i) Baseline episode spending from baseline year 1 is weighted at 17 percent.(ii) Baseline episode spending from baseline year 2 is weighted at 33 percent.(iii) Baseline episode spending from baseline year 3 is weighted at 50 percent.(4)Exception for high episode spending. CMS applies a high-cost outlier cap to baseline episode spending at the 99th percentile of regional spending for each of the MS-DRG/HCPCS episode types specified in § 512.540(a)(1)(ii).(5)Exclusion of incentive programs and add-on payments under existing Medicare payment systems. Certain Medicare incentive programs and add-on payments are excluded from baseline episode spending by using, with certain modifications, the CMS Price (Payment) Standardization Detailed Methodology used for the Medicare spending per beneficiary measure in the Hospital Value-Based Purchasing Program.(6)Prospective normalization factor. Based on the episodes in the most recent calendar year of the baseline period, CMS calculates a prospective normalization factor, which is a multiplier that ensures that the average risk adjusted target price does not exceed the average unadjusted target price, by doing the following: (i) CMS applies risk adjustment multipliers, as specified in § 512.545(a)(1) through (3), to the most recent baseline year episodes to calculate the estimated risk-adjusted target price for all performance year episodes.(ii) CMS divides the mean of the preliminary target price for each episode across all hospitals and regions by the mean of the estimated risk-adjusted target price calculated in § 512.540(b)(6)(i) for the same episode types across all hospitals and regions.(7)Prospective trend factor. CMS calculates the following: (i) The average regional episode spending for each MS-DRG/HCPCS episode type using the most recent calendar year of the applicable baseline period.(ii) The difference between the average regional spending for each MS-DRG/HCPCS episode type during the most recent calendar year of the baseline period and the average regional spending for each MS-DRG/HCPCS episode type during the first years of the baseline period to determine the prospective trend factor.(8)Communication of preliminary target prices. CMS communicates the preliminary target prices for each MS-DRG/HCPCS episode type for each region to the TEAM participant before the performance year in which they apply.(c)Discount factor. CMS incorporates an episode category specific discount factor of 1.5 percent for CABG and Major Bowel episodes and 2 percent for LEJR, SHFFT, and Spinal Fusion episodes to the TEAM participant's preliminary episode target prices intended to reflect Medicare's potential savings from TEAM.