Spine Under Medicare's New Payment Models
TEAM, WISeR and ASM: what each measures, who carries the risk, and what our spine service line does about it
- Audience
- Hospital leadership, Spine service line, Case management, quality, revenue cycle
- Duration
- 30 minutes (paced estimate ~27 min)
- Slides
- 27 across 5 sections
- References
- 30 verified · 0 attributed images
- Presenter
- Aaron Wey, MD, FAAOS, FACS
- Version
- 1.0 · ready
- Created
- 2026-10-18
- Last updated
- 2026-10-18
- Literature reviewed through
- CMS rules, guides and participant files read October 18, 2026
Research record: research/spine-payment-models/
Learning objectives
- Explain what TEAM, WISeR and ASM each measure and who carries the financial risk.
- Know exactly which spine services and which local hospitals and clinicians each model covers in New Jersey.
- Identify the clinical and operational levers that move spinal fusion episode spending and quality.
- Understand how gainsharing can align surgeons and the hospital under TEAM, and its legal conditions.
- Agree a 90-day plan, a monthly dashboard and a physician lead for the spine service line.
Spine Under Medicare's New Payment Models
TEAM, WISeR and ASM: what each one measures, who carries the risk, and what our spine service line does about it
Outline
- 1.Why nowslide 1
- 2.TEAMslide 6
- 3.Prior authorizationslide 11
- 4.ASMslide 14
- 5.Our planslide 20
All slides
Spine Under Medicare's New Payment Models
TEAM, WISeR and ASM: what each one measures, who carries the risk, and what our spine service line does about it
Three programs, all live or arriving within a year
How we got here, and what is coming
Who carries the risk under each model
Where each model touches a Medicare back-pain patient
TEAM: the hospital's fusion episode
Mandatory since January 2026, for every Bergen and Hudson hospital
Transforming Episode Accountability Model
- Mandatory for acute care hospitals in selected areas, January 2026 to December 2030; New York-Newark-Jersey City is selected CMS 2026 CMS 2026
- Five episodes: joint replacement, hip and femur fracture, CABG, major bowel surgery, and spinal fusion
- Spinal fusion triggers: inpatient fusion DRGs (523 to 525 added October 2026) and hospital outpatient 22551, 22554, 22612, 22630, 22633 CMS 2026
- The episode: the procedure plus 30 days after discharge; nearly all Medicare Part A and B spending counts CFR 2026
- Primary care referral must be part of discharge planning
- Not in TEAM: surgery centers. A fusion done in an ambulatory surgery center does not start a TEAM episode CMS 2024
Target price, reconciliation and quality
| Element | How CMS sets it |
|---|---|
| Target price | Regional (Middle Atlantic) spending for the same episode type over 3 baseline years, weighted 17, 33 and 50%, risk-adjusted and trended CFR 2026 |
| Discount | 2% for spinal fusion, joint replacement and hip fracture; 1.5% for CABG and bowel CFR 2026 |
| Reconciliation | Actual 30-day Medicare spending is compared with the target; the hospital is paid the savings or repays the excess, within its track's limits |
| Tracks | Track 1 had no downside risk in year 1; most hospitals are now in two-sided risk, with up to ±20% stop-loss and stop-gain in Track 3 CMS 2025 |
| Quality | A composite quality score adjusts the result: hospital-wide readmissions, patient safety and harm measures, and from 2028 a patient-reported Information Transfer measure for fusion CFR 2026 |
Target prices are set per DRG or outpatient code. Implant cost does not change Medicare episode spending; it changes the hospital's margin, and documented savings can fund gainsharing.
Where the 30-day money actually goes
Before surgery
- Indication and operation matched to the patient
- Optimisation: glucose, nicotine, nutrition, bone health
- Expected discharge destination decided at booking
- Primary care physician identified
In the hospital
- Length of stay and same-day mobilisation
- Complications and harm events (patient safety measures)
- Discharge home with services rather than to a facility
- Primary care referral in the discharge plan
The 30 days after
- Readmissions and emergency visits
- Skilled nursing and rehabilitation stays
- Wound and pain problems handled in clinic, not the ED
- A call within 48 hours and a two-week visit
Practice levers, not CMS rules. Each one maps to episode spending or to a TEAM quality measure.
Gainsharing: how surgeons can share in TEAM savings
- Physicians and physician groups can be TEAM collaborators with the hospital CFR 2026
- The arrangement must be written, signed before care is given, and voluntary
- Selection must be based on quality criteria, never on the volume or value of referrals
- Payments come only from CMS reconciliation payments or documented internal cost savings, at most once a year
- The surgeon must meet the hospital's quality criteria and have cared for a TEAM patient that year
- Downside sharing is capped at 25% of the hospital's repayment per collaborator; care and device choice may not be restricted
WISeR and the hospital outpatient program
Prior authorization in traditional Medicare, live in New Jersey now
Which spine services need prior authorization in New Jersey
| Service | Codes | Program |
|---|---|---|
| Epidural steroid injections | 62321, 62323, 64479, 64480, 64483, 64484 | WISeR CMS 2026 |
| Kyphoplasty and vertebroplasty | 22510 to 22515 | WISeR |
| Cervical fusion without decompression | 22554 | WISeR |
| Spinal cord stimulator, paddle lead | 63655 | WISeR |
| ACDF in a hospital outpatient department | 22551, 22552 | Hospital outpatient prior authorization CMS 2026 |
| Spinal cord stimulator, percutaneous | 63650 | Hospital outpatient prior authorization |
| Facet procedures; image-guided lumbar decompression | Facet codes; PILD | Not in WISeR: facets excluded, PILD delayed CMS 2026 |
Traditional Medicare only; Medicare Advantage plans run their own prior authorization. WISeR applies in the office, the surgery center and the hospital outpatient department.
How a WISeR request works
ASM: the clinician's back-pain score
Mandatory from 2027 in selected areas; not Bergen or Hudson today, and worth preparing for anyway
Ambulatory Specialty Model
- Mandatory, finalized in the 2026 physician fee schedule rule; performance years 2027 to 2031, payment years 2029 to 2033 CMS 2025 CMS 2025
- Two conditions: low back pain and heart failure. Low back pain cohort: orthopaedic surgery, neurosurgery, PM&R, pain management, interventional pain and anaesthesiology
- Scored against peers on quality, cost, improvement activities and interoperability; quality and cost per clinician, the other two per group CMS 2026
- Adjustment on all Part B professional payments: ±9% in 2029 and 2030, then ±10, ±11 and ±12% CFR 2026
- Eligibility: 20 or more low back pain episodes two years earlier, and practice in a selected area
- 3,319 clinicians in 46 states in the final low back pain cohort; the participant portal opened September 2026 CMS 2026 CMS 2026
ASM in New Jersey: selected areas, and ours is not one of them
Selected
- Lakewood-New Brunswick: Middlesex, Monmouth, Ocean, Somerset
- Trenton-Princeton: Mercer
- Vineland: Cumberland
- Allentown area: Warren; Wilmington area: Salem
- 132 New Jersey low back pain clinicians, 120 of them in Lakewood-New Brunswick
Not selected
- New York-Jersey City-White Plains: Bergen, Hudson, Passaic
- Newark: Essex, Morris, Union, Sussex, Hunterdon
- Camden and Atlantic City
- A clinician is assigned to the area where most of their episodes are seen
CMS selected metropolitan divisions by stratified random sampling. New clinicians can be added each year from 2028 if they meet the criteria in a selected area. CMS 2025 CMS 2026 Census 2023
The low back pain episode and its quality measures
| Element | Definition |
|---|---|
| Trigger | An office visit, therapy or manipulation claim plus a confirming claim within 60 days, both coded low back pain CMS 2023 |
| Not a trigger | Spine surgery: no episode opens if surgery falls from 90 days before to 60 days after the trigger |
| Length | A 120-day window, extended by each new qualifying claim: 120 to 484 days |
| Costs counted | Surgery, hospital stays, injections, imaging, therapy, medications, post-acute care, equipment |
| Excluded | Cauda equina, infection, osteoporotic fracture, myelopathy, trauma, tumour |
| Quality, 2027 | Functional status change (a patient-reported outcome), depression screening, BMI screening, high-risk medications in older adults CMS 2026 |
| Proposed for 2027 | Oswestry or PROMIS functional outcome measure; a claims measure of lumbar MRI use for low back pain CMS 2026 |
Why we prepare for ASM anyway
- Our clinicians can be pulled in: a surgeon whose episodes shift to a selected area, or a newly eligible clinician added from 2028 CFR 2026
- The same cost measure already exists in MIPS: the low back pain cost measure sits in the Rehabilitative Support for Musculoskeletal Care value pathway CMS 2025
- The required workflows are good practice: a written collaborative care arrangement with primary care, closing the loop to the PCP, social-needs screening, certified EHR CMS 2026
- Outcome scores are the currency of ASM, of TEAM's future fusion measure, and of every commercial bundle
- Commercial payers copy Medicare: a documented, low-waste back-pain pathway is a contracting asset
Related programs worth knowing
| Program | What it does | Why it matters to spine |
|---|---|---|
| NOPAIN Act | Separate Medicare payment for qualifying non-opioid pain treatments in hospital outpatient and surgery-center settings, 2025 through 2027 CMS 2024 | Multimodal, opioid-sparing protocols can be paid separately; the product list is updated quarterly CMS 2025 |
| MIPS value pathways | No spine-specific pathway; Rehabilitative Support for Musculoskeletal Care holds the low back pain cost measure CMS 2025 | Our clinicians' MIPS scores already reflect back-pain episode cost |
| CJR-X (2028) | National mandatory joint-replacement model; TEAM hospitals excluded CMS 2026 | Not spine, but the same hospital teams will run both |
| The consolidation debate | Commentary argues two-sided specialist risk pushes small practices toward larger groups AJMC 2026 | Data infrastructure built early protects independent surgeons |
Our plan
One physician lead, one dashboard, one pathway
A spine service-line dashboard, reviewed monthly
| Measure | Model it moves | Source | Owner |
|---|---|---|---|
| Fusion volume by DRG and site (inpatient, outpatient) | TEAM | Finance, CMS TEAM data | Service line |
| Length of stay; discharge home vs facility | TEAM | EHR, case management | Case management |
| 30-day readmissions and ED visits | TEAM quality and spending | Quality, CMS data | Quality |
| Complications and harm events | TEAM quality | Quality | Quality, surgeons |
| Implant cost per case | Hospital margin; gainsharing | Supply chain | Value analysis |
| Outcome scores before and after (Oswestry or PROMIS) | ASM, TEAM from 2028, commercial | Clinic and EHR | Surgeons, clinic |
| WISeR and outpatient prior authorization: approval rate, days, gold-card status | WISeR | Revenue cycle | Revenue cycle, clinic |
TEAM participants receive CMS claims data on their episodes. The first job is to get that data to the service line every month.
What I will own as physician lead
- Translate the rules for the service line, and keep this deck current as CMS changes them
- Chair a monthly spine episode review: the dashboard, outliers, readmissions, and one case each month
- Co-design the TEAM collaborator arrangement with administration and counsel: quality criteria, savings sources, written in advance
- Standardise the pathway: pre-operative optimisation, discharge destination at booking, a 48-hour call and two-week visit
- Set documentation standards for WISeR and outpatient prior authorization, and drive our clinicians toward gold-card status
- Stand up outcome collection in clinic, and an ASM-ready back-pain pathway with primary care
What I am asking for
Common claims about these models, checked against CMS
| You may hear | What CMS's documents say |
|---|---|
| ASM payments start in 2028 | Performance starts in 2027; payment adjustments start in 2029 CFR 2026 |
| ASM covers all of New Jersey | Only selected areas; Bergen, Hudson, Passaic and the Newark division are not selected CMS 2025 |
| A surgery-center fusion counts in the hospital's TEAM episode | It does not start a TEAM episode; TEAM episodes start only at TEAM hospitals CMS 2024 |
| WISeR covers cervical fusion and lumbar decompression | Only cervical code 22554; outpatient ACDF is a separate program; lumbar decompression is delayed CMS 2026 |
| TEAM creates site-neutral fusion prices | Target prices are set per DRG or outpatient code CFR 2026 |
Five things to remember
- TEAM is live and it is the hospital's risk: every spinal fusion episode, surgery plus 30 days, against a discounted regional target
- WISeR and the outpatient program are live: injections, kyphoplasty, 22554, ACDF in the outpatient department; the facility needs the tracking number
- ASM is the clinician's risk from 2027 in selected areas; not Bergen or Hudson today, and worth preparing for
- The same levers move all three: selection, optimisation, length of stay, discharge home, readmissions, outcome scores
- Gainsharing aligns us: written, quality-based, paid from real savings. I will lead the work
Sources: CMS rules, guides and participant files
1.CMS. Ambulatory Specialty Model (ASM) model page. CMS Innovation Center. 2026.
2.CMS. ASM Model Overview Fact Sheet. CMS Innovation Center. 2025.
3.CMS. ASM Frequently Asked Questions. CMS Innovation Center. 2026.
4.CMS. ASM Performance Categories Reporting Factsheet. CMS Innovation Center. 2026.
5.CMS. ASM Mandatory Geographic Areas (XLSX). CMS Innovation Center. 2025.
6.CMS. ASM Participants: Revised Master Final Participant List CY27 (CSV). CMS (data.cms.gov). 2026.
7.CMS. ASM Participant Office Hours slides (September 30, 2026). CMS Innovation Center. 2026.
8.CMS. CY 2026 Physician Fee Schedule final rule, 90 FR 49266 (FR Doc 2025-19787). Federal Register / CMS. 2025.
9.CMS. CY 2027 Physician Fee Schedule proposed rule, 91 FR 43842 (FR Doc 2026-14327). Federal Register / CMS. 2026.
10.CMS. Low Back Pain Measure Information Form (MIF), 2024 performance period. CMS Quality Payment Program. 2023.
11.AJMC. Containing Chronic Disease Costs With the Ambulatory Specialty Model (Kumar, Kannarkat, Kannarkat). American Journal of Managed Care. 2026.
12.CMS. Transforming Episode Accountability Model (TEAM) model page. CMS Innovation Center. 2026.
13.CMS. TEAM Overview Fact Sheet. CMS Innovation Center. 2025.
14.CMS. TEAM Participant List, 2026Q3 (XLSX). CMS Innovation Center. 2026.
15.CFR. 42 CFR Part 512 (TEAM subpart E; CJR-X subpart F; ASM subpart G), current as of 2026-10-13. eCFR (Office of the Federal Register). 2026.
16.CMS. FY 2025 IPPS/LTCH PPS final rule, 89 FR 68986 (FR Doc 2024-17021), TEAM established. Federal Register / CMS. 2024.
17.CMS. FY 2027 IPPS/LTCH PPS final rule, 91 FR 49570 (FR Doc 2026-15833). Federal Register / CMS. 2026.
18.CMS. Comprehensive Care for Joint Replacement (CJR) Model page. CMS Innovation Center. 2026.
19.CMS. BPCI Advanced model page. CMS Innovation Center. 2026.
20.CMS. WISeR (Wasteful and Inappropriate Service Reduction) Model page. CMS Innovation Center. 2026.
21.CMS. WISeR Provider and Supplier Operational Guide, Version 7.0. CMS Innovation Center. 2026.
22.CMS. Implementation of Prior Authorization for Select Services for the WISeR Model, 90 FR 28749 (FR Doc 2025-12195). Federal Register / CMS. 2025.
23.CMS. Delayed Implementation of Certain Prior Authorization for Select Services for the WISeR Model, 91 FR 17282 (FR Doc 2026-06616). Federal Register / CMS. 2026.
24.CMS. WISeR Model notice correction, 91 FR 17282-17283 (FR Doc 2026-06617). Federal Register / CMS. 2026.
25.CMS. WISeR Model Frequently Asked Questions. CMS Innovation Center. 2026.
26.CMS. CY 2025 OPPS/ASC Final Rule Fact Sheet (CMS-1809-FC). CMS. 2024.
27.CMS. Non-Opioid Quarterly Implementation Process (updated December 2025). CMS. 2025.
28.Census. CBSA, Metropolitan Division, and CSA delineation file (List 1), July 2023. U.S. Census Bureau / OMB. 2023.
29.CMS. Prior Authorization for Certain Hospital Outpatient Department (OPD) Services. Centers for Medicare & Medicaid Services. 2026.
30.Novitas. WISeR (Wasteful and Inappropriate Service Reduction) model: Medicare JL. Novitas Solutions. 2026.
Full reference list with DOI and PubMed links is available in the online references view.
This deck, with every CMS source linked
Slides, speaker notes, and the CMS rules, guides and participant files behind every number. I will keep it current as CMS updates the models.