What Is CJR-X? A Guide to Medicare’s 2028 Joint Replacement Model

CJR-X start date update: CMS originally proposed an October 1, 2027 start date for CJR-X. In the FY 2027 IPPS final rule, CMS moved the implementation date to January 1, 2028.

CMS is expanding Medicare's approach to joint replacement payments with the Comprehensive Care for Joint Replacement Expanded Model, or CJR-X. Beginning January 1, 2028, CJR-X will make most eligible hospitals nationwide financially accountable for the cost and quality of certain hip, knee, and ankle replacement episodes.¹

The CJR-X Medicare model builds on the earlier Comprehensive Care for Joint Replacement Model, which CMS tested from 2016 through 2024. According to CMS, the earlier model generated more than $100 million in Medicare savings while maintaining quality of care.² CJR-X takes that concept nationwide and expands accountability across inpatient and hospital outpatient joint replacement procedures.

For organizations preparing for CJR-X in 2028, the change reaches beyond the surgery itself. The episode includes related Medicare spending through the first 90 days of recovery, which can include rehabilitation, follow-up treatment, post-acute care, emergency department visits, and readmissions.²

Understanding the CJR-X requirements now gives organizations time to examine current joint replacement pathways, episode spending, outcomes collection, and post-discharge care before the model begins.

What Is the CJR-X Medicare Model?

CJR-X is a mandatory Medicare episode-based payment model focused on lower extremity joint replacements.

CMS finalized CJR-X as part of the FY 2027 Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System final rule on July 31, 2026. The model will begin January 1, 2028.¹

Under traditional Medicare fee-for-service payment, individual providers and suppliers generally receive separate payments for services provided during a patient's joint replacement and recovery.

CJR-X keeps those underlying Medicare payment systems in place, but adds another layer of financial accountability.

Hospitals participating in the model will be responsible for Medicare spending and quality associated with eligible joint replacement episodes. CMS will compare episode spending with a target price and use quality performance when determining potential payments or repayments.

The CJR-X episode covers care from the qualifying procedure through 90 days following inpatient discharge or the eligible outpatient procedure. CMS states that this may include Medicare spending associated with the surgery, hospitalization, physical therapy, and other follow-up treatment.²

This gives hospitals a financial interest in what happens across much more of the patient's recovery.

A successful surgery followed by an expensive or poorly coordinated recovery may still affect episode performance.

What Are the CJR-X Requirements?

One of the biggest questions surrounding the new rule is which organizations and procedures fall under the CJR-X requirements.

CMS has finalized CJR-X as a nationwide mandatory model for most qualifying hospitals.

Hospital participation requirements

Most hospitals paid under both the Medicare Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS) will be required to participate.¹

CMS has identified several exclusions. These include:

• Hospitals participating in the Transforming Episode Accountability Model, or TEAM

• Hospitals located in Maryland

• Hospitals that are not paid under both IPPS and OPPS²

TEAM participants will remain outside CJR-X while participating in TEAM. The two models should therefore be treated as related but separate Medicare initiatives rather than programs that eligible hospitals will necessarily manage simultaneously. For a closer look at the differences in episode length, procedure scope, participation, and financial accountability, see our guide to CJR-X vs TEAM.²

Eligible joint replacement procedures

CJR-X centers on lower extremity joint replacement procedures, including qualifying hip, knee, and ankle replacements performed in inpatient and hospital outpatient settings.¹

Eligible inpatient episodes are associated with specified Medicare Severity Diagnosis-Related Groups, including:

• MS-DRG 469: Major hip and knee joint replacement or reattachment of lower extremity with major complications or comorbidities, or total ankle replacement

• MS-DRG 470: Major hip and knee joint replacement or reattachment of lower extremity without major complications or comorbidities

• MS-DRG 521: Hip replacement with principal diagnosis of hip fracture with major complications or comorbidities

• MS-DRG 522: Hip replacement with principal diagnosis of hip fracture without major complications or comorbidities

CJR-X also includes eligible hospital outpatient hip and knee replacement procedures.

Including both inpatient and outpatient procedures means organizations will need visibility across multiple surgical pathways rather than treating CJR-X as an inpatient-only initiative.

90-day episode requirement

Each CJR-X episode continues through 90 days after discharge from an inpatient hospitalization or the date of an eligible outpatient procedure.

With limited exclusions, related Medicare Part A and Part B services can contribute to episode spending.

For joint replacement, that makes post-discharge recovery particularly relevant. Physical therapy, post-acute care, hospital utilization, and other related services may occur weeks after the surgery while still falling inside the CJR-X episode.

When Does CJR-X Start?

The finalized CJR-X start date is January 1, 2028.¹

This is important because earlier information about CJR-X may still list October 1, 2027.

CMS originally proposed October 1, 2027, but changed the implementation date in the final FY 2027 IPPS rule. The final rule establishes January 1, 2028 as the beginning of CJR-X.¹

Organizations researching CJR-X 2028 should therefore rely on the finalized January date rather than earlier material based on the proposed rule.

The additional preparation period gives hospitals time to examine their existing joint replacement performance before financial accountability begins.

That work can include reviewing spending variation, current post-acute utilization, rehabilitation patterns, patient outcomes, and care coordination processes.

How Does CJR-X Financial Accountability Work?

CJR-X does not replace Medicare fee-for-service claims with one prospective payment.

Providers and suppliers will continue to receive Medicare payments through their existing payment systems. CMS will then evaluate spending retrospectively against an established target price.

After the applicable performance period, CMS compares actual episode spending with the hospital's target.

Depending on the hospital's spending and quality performance, the organization may receive an additional reconciliation payment or owe money back to Medicare.

This structure means episode costs occurring outside the hospital can affect financial results.

Consider a patient undergoing total knee replacement.

The procedure may go as planned and the patient may be discharged without complications. During the following several weeks, however, the patient could have difficulty with mobility, miss rehabilitation appointments, visit the emergency department, or require additional post-acute services.

Those costs can fall inside the 90-day CJR-X episode.

Now consider another patient with a similar procedure who receives clear preoperative education, begins an appropriate rehabilitation program, completes prescribed home exercises, attends follow-up appointments, and reports concerning symptoms before they result in higher-cost care.

The difference between those recovery pathways illustrates why post-discharge care has greater financial relevance under CJR-X.

How Does Quality Factor Into CJR-X Requirements?

CJR-X links financial performance with quality rather than rewarding lower spending by itself.

CMS designed the model so hospitals must meet an episode-quality threshold to qualify for certain reconciliation payments.

Quality measurement under CJR-X includes areas such as complications, post-procedure hospital utilization, patient experience, and patient-reported outcomes.

The inclusion of patient-reported outcomes is particularly relevant for joint replacement.

Claims data can show where patients received care and what Medicare paid, but they do not fully describe changes in pain, mobility, or function after surgery.

Consistent outcomes collection can provide another view of recovery while supporting the quality measurement requirements associated with the model.

CJR-X also preserves Medicare beneficiaries' ability to choose their healthcare providers.² Hospitals may develop stronger post-acute partnerships and standardized pathways, but patients maintain their choice of Medicare-participating providers and services.

That makes coordination and data visibility across settings especially important.

How to Prepare for CJR-X Before 2028

Preparation for CJR-X can begin by mapping the entire joint replacement episode rather than focusing primarily on the surgical encounter.

Organizations can examine the patient pathway from preoperative preparation through at least 90 days after the procedure and identify where variation occurs.

Areas to assess include:

• Joint replacement episode spending

• Hospital readmissions

• Emergency department utilization

• Skilled nursing facility use

• Home health utilization

• Outpatient rehabilitation

• Rehabilitation adherence

• Complication rates

• Patient-reported outcomes

• Variation between surgeons or facilities

• Gaps in post-discharge follow-up

• Data visibility across care settings

Rehabilitation deserves particular attention because CMS specifically identifies physical therapy as part of the care that can occur during the CJR-X recovery period.²

Organizations may also want to assess how patients are supported between formal encounters.

Digital care pathways, home exercise programs, patient education, remote monitoring, and outcomes collection can provide greater visibility into the recovery period. They can also help care teams identify when progress differs from expectations and determine when additional clinical follow-up may be appropriate.

The goal should not be to reduce services simply because they contribute to episode spending. CJR-X links cost with quality, meaning care decisions still need to support patient outcomes while limiting unnecessary utilization.

What CJR-X Means for Joint Replacement Care in 2028

CJR-X represents a major expansion of Medicare's use of episode-based payment for joint replacement.

Beginning January 1, 2028, most eligible hospitals nationwide will assume greater accountability for Medicare spending and quality for qualifying hip, knee, and ankle replacement episodes.¹

The CJR-X Medicare requirements extend well beyond the procedure. Hospitals will need to understand what happens during the full 90-day episode, including rehabilitation, post-acute care, complications, follow-up treatment, and patient outcomes.

Organizations that begin assessing these areas before 2028 can identify where variation currently exists and where stronger coordination may support both patient recovery and financial performance under the model.

References

¹ Centers for Medicare & Medicaid Services. FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final Rule (CMS-1849-F). July 31, 2026.
https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-long-term-care-hospital-prospective-payment

² Centers for Medicare & Medicaid Services. CMS Announces Nationwide Expansion of Proven Joint Replacement Program. July 31, 2026.
https://www.cms.gov/newsroom/press-releases/cms-news-cms-announces-nationwide-expansion-proven-joint-replacement-program

³ Centers for Medicare & Medicaid Services. CJR-X Model. CMS Innovation Center.
https://www.cms.gov/priorities/innovation/innovation-models/cjr-x