TEAM, WISeR and ASM: what each one measures, who carries the risk, and what our spine service line does about it
Mandatory since January 2026, for every Bergen and Hudson hospital
| 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.
Practice levers, not CMS rules. Each one maps to episode spending or to a TEAM quality measure.
Prior authorization in traditional Medicare, live in New Jersey now
| 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.
Mandatory from 2027 in selected areas; not Bergen or Hudson today, and worth preparing for anyway
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
| 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 |
| 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 |
One physician lead, one dashboard, one pathway
| 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.
| 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 |
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.
Slides, speaker notes, and the CMS rules, guides and participant files behind every number. I will keep it current as CMS updates the models.