CJR-X: What Physical Therapy Practices Need to Know

The Comprehensive Care for Joint Replacement Expanded Model, commonly called CJR-X, could change how hospitals coordinate and pay for care following hip, knee, and ankle replacement procedures.

Under the proposed CJR-X model, participating hospitals would be financially accountable for the quality and cost of an eligible joint replacement episode, beginning with the inpatient or outpatient procedure and continuing through 90 days after discharge. The episode would generally include Medicare Part A and Part B services such as the procedure, hospital care, follow-up visits, and post-discharge physical therapy.¹

This structure gives physical therapy practices an opportunity to become closer partners to hospitals and orthopedic groups. It also creates pressure to demonstrate measurable outcomes, communicate across care settings, and help manage post-acute utilization.

CMS proposed CJR-X in the fiscal year 2027 Inpatient Prospective Payment System rule on April 10, 2026. If finalized as proposed, the model would begin October 1, 2027, and become the first mandatory nationwide CMS episode-based payment model.¹ Because the proposal may change before implementation, organizations should follow the final rule and subsequent CMS guidance.

What Is the CJR-X Model?

CJR-X is a proposed expansion of the original Comprehensive Care for Joint Replacement Model, which operated from 2016 through 2024 in selected metropolitan areas.

The original CJR model held participating hospitals responsible for Medicare spending and quality across a joint replacement episode. CMS reports that the model generated Medicare savings while maintaining quality of care. The proposed CJR-X model would apply similar episode-based principles on a much broader scale.²

CJR-X would cover eligible Original Medicare patients receiving certain lower-extremity joint replacement procedures in inpatient and hospital outpatient settings. These include qualifying:

• Total knee arthroplasties

• Total hip arthroplasties

• Hip replacements associated with hip fractures

• Total ankle replacements

The episode would begin with the qualifying procedure and continue through the first 90 days following discharge. Medicare would continue paying each provider under the applicable payment system. At the end of a performance period, CMS would compare the hospital’s episode spending against a target price and assess the hospital’s quality performance.¹

Depending on those results, the hospital could receive a reconciliation payment from CMS or be required to repay a portion of episode spending.

Is CJR-X Mandatory?

CMS has proposed making CJR-X mandatory for most eligible hospitals paid under both the Inpatient Prospective Payment System and the Outpatient Prospective Payment System. Certain hospitals would be excluded, including hospitals participating in the Transforming Episode Accountability Model, hospitals in Maryland, and facilities that do not meet the applicable payment-system requirements.¹

Hospitals participating in TEAM would remain outside CJR-X while participating in that model. TEAM uses a 30-day episode, while CJR-X would use a 90-day episode for lower-extremity joint replacements.¹

The nationwide scope matters for physical therapy practices because joint replacement referrals may increasingly be influenced by episode cost, care coordination, outcomes reporting, and the hospital’s ability to manage recovery across the full 90-day period.

In this environment, a therapy provider may be viewed in one of two ways:

1. As a care partner that helps the hospital manage outcomes, communication, and utilization.

2. As an episode expense that the hospital has limited ability to monitor or influence.

Practices that can show their value through data and coordinated care may be better positioned to build or maintain preferred relationships.

Why CJR-X Matters for Physical Therapy Practices

Physical therapy falls directly within the post-discharge services included in a CJR-X episode. CMS specifically identifies physical therapy and other outpatient or home-based rehabilitation as parts of the recovery period that hospitals may need to coordinate.¹

That means hospital leaders will likely look closely at factors such as:

• When therapy begins

• The number and frequency of visits

• Functional improvement

• Adherence to the home exercise program

• Avoidable emergency department visits

• Hospital readmissions

• Transitions to skilled nursing or home health care

• Communication between the therapy practice and surgical team

• Patient-reported outcome completion

The purpose should not be to reduce visits without regard to patient need. Instead, the goal is to match services to each patient’s condition, recovery progress, risk factors, and ability to manage care at home.

A patient recovering as expected may benefit from a hybrid plan that combines in-person visits with digital exercises and remote follow-up. A patient reporting increasing pain, poor adherence, functional decline, or wound concerns may need earlier intervention or escalation to the surgical team.

Physical therapy practices that can distinguish between these groups may help reduce avoidable utilization while supporting patient recovery.

How Quality Performance Works in CJR-X

Cost performance alone would not qualify a hospital for a CJR-X reconciliation payment.

CMS proposes using a “quality first” approach. A hospital would need to meet a minimum composite quality standard before receiving a reconciliation payment, even when episode spending comes in below the hospital’s target price.¹

The proposed composite quality score would draw from five measures:

• Complications following elective total hip or total knee arthroplasty

• Hospital visits within seven days of hospital outpatient surgery

• Hospital Consumer Assessment of Healthcare Providers and Systems results

• Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems results

• The hospital-level THA/TKA patient-reported outcome-based performance measure

The inclusion of the THA/TKA PRO-PM gives rehabilitation providers an important role. Functional recovery is one of the primary areas therapy teams assess throughout joint replacement care.

Practices that already collect instruments such as the HOOS, JR. and KOOS, JR. may be in a stronger position to support hospital reporting workflows. However, collecting a measure during a therapy visit is only one part of the process. Data must also be complete, available at the required time points, and shared in a form the hospital can use.

Patient-Reported Outcomes and CJR-X

Patient-reported outcomes help show how joint replacement affects pain, mobility, daily activities, and function from the patient’s perspective.

For CJR-X, CMS proposes including the existing hospital-level THA/TKA patient-reported outcome-based performance measure in the composite quality score.¹ This measure relies on preoperative and postoperative patient data rather than measuring recovery only through claims or complication rates.

Physical therapy practices may be well positioned to assist because they commonly have repeated contact with patients during the recovery period. They can also respond when outcomes indicate slower-than-expected progress.

A scalable outcomes process may include:

• Electronic delivery of preoperative assessments

• Automated reminders through text or email

• Completion tracking across locations

• Standardized scoring

• Follow-up workflows for missing assessments

• Integration or data sharing with hospital partners

• Documentation of clinical action when a score identifies a concern

Paper forms and manual phone calls may work for a small patient population, but they become difficult to maintain across hundreds or thousands of joint replacement episodes. Digital collection can reduce manual administrative work and give care teams faster visibility into functional recovery.

What Hospitals May Look for in a Physical Therapy Partner

CMS proposes encouraging hospitals to work with physicians and post-acute providers to coordinate care across the procedure and recovery period.¹ As hospitals prepare for CJR-X, many may assess whether their therapy partners can contribute to both cost management and quality performance.

Practices may be better positioned for collaboration when they have:

• A meaningful volume of hip, knee, or ankle replacement patients

• Existing hospital or orthopedic referral relationships

• Standardized joint replacement protocols

• Electronic patient-reported outcome collection

• Digital home exercise program delivery

• A process for identifying clinical warning signs

• Consistent communication with referring providers

• The ability to report utilization and functional progress

• Support for patients between in-person visits

• Defined escalation pathways

No single technology or service automatically makes a practice a strong CJR-X partner. Hospitals will likely value a combination of reliable care delivery, measurable results, responsive communication, and operational consistency.

Smaller organizations should not assume that collaboration is limited to large regional groups. A smaller practice with strong orthopedic relationships, documented results, and dependable communication may offer more value than a larger network that cannot provide episode-level visibility.

Questions to Ask Before Pursuing a CJR-X Partnership

Before approaching a hospital or orthopedic group, practices should assess whether they can support the needs of an episode-based arrangement.

Questions may include:

• How many joint replacement patients do we treat each year?

• Which hospitals and surgeons refer these patients?

• Can we identify patients by procedure, facility, and episode?

• Which outcomes do we collect?

• When are those outcomes collected?

• What percentage of patients complete the required assessments?

• Can we share data securely with the hospital?

• How quickly do we communicate clinical warning signs?

• Do clinicians follow a consistent care pathway?

• Can we show differences in visits, outcomes, adherence, or readmissions?

• Can we support patients who do not respond to traditional outreach?

• Who within our organization would manage the hospital relationship?

These questions can help a practice identify operational gaps before negotiating a collaboration or gainsharing arrangement.

Why Post-Acute Care Can Determine CJR-X Performance

The surgical procedure is only one portion of the 90-day CJR-X episode. Post-acute utilization can have a meaningful effect on total Medicare spending.

Emergency visits, hospital readmissions, skilled nursing facility stays, home health use, imaging, follow-up care, and outpatient rehabilitation may all affect episode performance when included under the model.

Physical therapy teams see patients during a period when several preventable problems may emerge, including:

• Poor exercise adherence

• Increasing pain or swelling

• Reduced mobility

• Fear of movement

• Medication-related barriers

• Transportation limitations

• Missed follow-up appointments

• Difficulty understanding discharge instructions

• Lack of support at home

A structured process for detecting and communicating these concerns can help the broader care team act earlier. For example, a patient who stops completing exercises and reports increasing pain may need outreach before the issue leads to an emergency visit or a preventable decline in function.

That role extends beyond delivering visits. It includes observing recovery, interpreting patient data, reinforcing the care plan, and communicating when a patient is moving outside expected recovery parameters.

How Remote Therapeutic Monitoring May Support CJR-X

Remote therapeutic monitoring can help rehabilitation teams collect information about therapy adherence, symptoms, and response to treatment between visits.

RTM is not a formal requirement of CJR-X. However, it may support several activities that align with the model, including:

• Monitoring home exercise adherence

• Identifying changes in pain or function

• Communicating with patients between appointments

• Adjusting the plan of care based on reported data

• Supporting patients who need more guidance

• Documenting treatment-management activities

• Identifying patients who may require escalation

Practices could use RTM before surgery to identify patients who have difficulty following a prehabilitation plan. Those patients may benefit from additional education or closer follow-up after surgery.

During the early postoperative period, monitoring may help identify increasing pain, declining adherence, limited mobility, or other concerns. During later recovery, it can provide added support for patients who are progressing more slowly or managing several barriers.

RTM billing must follow the applicable Medicare requirements and CPT guidance. It should not be treated as a guaranteed source of revenue or billed solely because a patient belongs to a CJR-X episode.

A Potential CJR-X Care Pathway

A digital joint replacement pathway could organize communication, exercises, monitoring, education, and outcome collection across the episode.

Before Surgery

The care team could:

• Deliver procedure and recovery education

• Assign a prehabilitation program

• Collect baseline patient-reported outcomes

• Assess barriers to adherence

• Confirm the patient’s preferred communication method

• Identify patients who may need closer follow-up

Days 0 Through 10 After Surgery

The care team could:

• Reinforce discharge instructions

• Monitor pain, mobility, and exercise participation

• Identify signs that require clinical follow-up

• Coordinate the first therapy visit

• Escalate concerns to the appropriate provider

Days 11 Through 90

The care team could:

• Progress the home exercise program

• Track functional improvement

• Adjust the frequency of support based on patient need

• Communicate milestones to the referring team

• Identify patients falling behind expected recovery

• Continue outcome and adherence tracking

Long-Term Outcome Follow-Up

The organization could use automated email, text messages, portal notifications, and staff outreach to collect the follow-up data required for patient-reported outcome reporting.

Using the same platform throughout the care journey can reduce fragmented communication and make it easier to connect preoperative information with postoperative recovery.

How Physical Therapy Practices Can Prepare for CJR-X

CJR-X is still proposed, but waiting until the model begins may leave limited time to build data-sharing processes and hospital relationships.

Practices can begin by taking several steps:

Review Current Joint Replacement Volume

Identify the number of hip, knee, and ankle replacement patients treated during the past year. Break the data down by procedure, referring surgeon, hospital, payer, and location when possible.

Standardize Outcomes Collection

Choose consistent measures and collection time points. Track completion rates and identify why assessments are missed.

Evaluate Digital Home Exercise Delivery

Determine how frequently exercises are delivered electronically and how well the practice can measure patient engagement outside the clinic.

Build Communication Workflows

Define which findings require communication with the surgeon or hospital and how quickly that communication should occur.

Train Teams on Value-Based Care

Clinicians and operational staff should understand why utilization, outcomes, patient experience, and care coordination matter under an episode-based model.

Meet With Hospital Partners

Ask hospital and orthopedic leaders how they are approaching CJR-X, which data they will need from post-acute providers, and how they plan to select collaborators.

Preparing for the Future of Joint Replacement Care

CJR-X could give physical therapy practices a larger role in joint replacement episodes, but that role will depend on their ability to demonstrate value.

Hospitals will need partners that can support functional recovery, collect patient-reported outcomes, identify warning signs, communicate across settings, and match care to patient needs. Practices that begin building these capabilities now may be better prepared to participate in preferred networks or future financial arrangements.

Medbridge brings care pathways, patient-reported outcome collection, digital home exercise programs, remote therapeutic monitoring, and provider education together in one connected system. Request a demo to learn how Medbridge can support joint replacement care and help your organization prepare for the proposed CJR-X model.

References

1. Centers for Medicare & Medicaid Services. “CJR-X (Comprehensive Care for Joint Replacement Expanded) Model.”
   https://www.cms.gov/priorities/innovation/innovation-models/cjr-x

2. Centers for Medicare & Medicaid Services. “CMS to Improve Patient Care Experience and Lower Costs for Hip, Knee, and Ankle Replacements.” April 10, 2026.
   https://www.cms.gov/newsroom/press-releases/cms-improve-patient-care-experience-lower-costs-hip-knee-ankle-replacements

3. Centers for Medicare & Medicaid Services. “FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule.” April 10, 2026.
   https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-ipps-long-term-care-hospital-prospective