2020 Hospital IQR Program Requirements

By Erin Heilman. Posted Oct 18, 2019 in Quality Reporting, Academy, IQR Program

Is your hospital ready for hospital quality reporting next year? Yes, I said next year! I know it may sound a little early, but when it comes to successfully fulfilling regulatory reporting requirements, it’s never too soon to start preparing.

To help you get ahead of the game, I’ve laid out the seven requirements your hospital will need to know to successfully complete one of the major regulatory programs in 2020: the Hospital Inpatient Quality Reporting (IQR) program. CMS finalized several changes to the program structure for next year, which can be found in their 2020 IPPS final rule.

History of the IQR program

As a reminder, the Hospital IQR program began in Fiscal Year (FY) 2010 to promote public transparency of quality. It is still technically considered “voluntary” but hospitals are incentivized to “volunteer” if they want to receive their full Annual Payment Update (APU) from Medicare (our nation’s first “Pay for Performance or P4P” program).

3,132 hospitals participated in FY 2019 (CY 2017). All those who participated received their full APU. There were 38 hospitals who elected not to participate. So in summary 57 (1.8%) IPPS hospitals failed to get their full APU either by electing non-participation or failure to file a notice of participation.

Hospitals who do not participate, or who participate but fail to meet program requirements are subject to a 25% reduction of their APU and are excluded from participation in the Hospital VBP Program, which is the only one of the CMS value-based programs where you can actually make money. 

Which Hospitals Are Eligible?

All acute care hospitals that are paid for providing services to Medicare beneficiaries (including Veterans Hospitals) may participate except Psychiatric, Rehab, Children’s, Cancer and Long-Term Care Hospitals. Critical Access Hospitals are exempt but are permitted and encouraged to participate because they are also required to participate in the Medicare Promoting Interoperability program. Maryland Hospitals do not participate in the Hospital IQR program.

2020 IQR Requirements Summary

These mandatory requirements are due quarterly:

1. Submit two chart-abstracted measures (Clinical Process of Care measures)

2. Submit population and sampling numbers (for chart-abstracted measures only)

3. Submit HCAHPS survey data

These mandatory requirements are due annually:

4. Submit four Electronic Clinical Quality Measures (eCQMs)

5. Complete the Data Accuracy and Completeness Acknowledgement (DACA)

6. Submit one Healthcare-Associated Infection (HAI) measure

You must also:

7. Regularly review your claims-based data

8. Meet audit requirements if selected for audit (validation).


1. Submit two Chart-Abstracted Measures Quarterly

In last year's IPPS Final Rule, CMS removed almost 40 measures across all value-based programs. I've included the measures being removed in each of these sections to remind you of what you used to do and how that's changed.

This chart shows the measures that are/were available/removed. 

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

VTE-6 Incidence of Potentially Preventable Venous Thromboembolism
IMM-2 Influenza Immunization
ED-1 Median Time from ED Arrival to Departure for Admitted ED Patients
ED-2* Admit Decision Time to ED Departure Time for Admitted Patients
PC-01 Elective Delivery (Web-based Measure)
Sepsis Severe Sepsis and Septic Shock: Management Bundle (Composite)

* ED-2 is being retained as an electronic measure

2020 Chart Abstracted Measure Requirements

Here is your work for 2020.

Requirement

REQUIREMENT: 
Hospitals must report on two chart-abstracted measures.

Submission

SUBMISSION METHOD:
QualityNet Secure Portal (Third party vendor authorization required.)

Deadline DEADLINE:
Quarterly Submission Deadlines

 

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

PC-01 Elective Delivery
(Web-based Measure)
CY 2020

(Q3 2019 due Feb 18, 2020)*
(Q4 2019 due May 18, 2020)*

Q1 2020 due Aug 17, 2020*
Q2 2020 due Nov 16, 2020*
Q3 2020 due Feb 15, 2021
Q4 2020 due May 17, 2021

Sepsis Severe Sepsis and Septic Shock: Management Bundle (Composite) CY 2020
*Chart-abstracted validation for FY 2022 applies to discharges during these quarters
 

Hospitals with five or fewer discharges

Hospitals with five or fewer discharges (both Medicare and non-Medicare combined) per measure in a quarter are not required to submit patient-level data.

PC-01 measure submission

Hospitals are required to enter PC-01 measure data through the web-based tool on a quarterly basis. These data are manually entered. They cannot be transmitted via xml file. If you do not deliver babies at your organization, you must enter zeroes for the PC-01 measure each quarter or you can submit an IPPS Measure Exception form.

 

2. Submit Population and Sample Size numbers Quarterly

Requirement

REQUIREMENT: 
Hospitals must submit population and sampling numbers for all chart-abstracted measures.

Submission

SUBMISSION METHOD:
QualityNet Secure Portal (Third party vendor authorization required.)

Deadline DEADLINE:
Quarterly Submission Deadlines

 

Short Name

Measure
Name 

Data Submission
Deadlines

PC-01 Elective Delivery
(Web-based Measure)

Q3 2019 due Feb 3, 2020
Q4 2019 due May 4, 2020
Q1 2020 due Aug 3, 2020
Q2 2020 due Nov 2, 2020
Q3 2020 due Feb 1, 2021
Q4 2020 due May 3, 2021

Sepsis Severe Sepsis and Septic Shock:
Management Bundle (Composite)

 

Hospitals must submit aggregate population and sample size counts for each chart-abstracted measure. This requirement only applies to populations for the chart-abstracted measures. It must be completed quarterly through the QualityNet Secure Portal.

Hospitals with five or fewer discharges

If you have five or fewer discharges per measure (Medicare and non-Medicare combined) in a quarter you are not required to submit patient-level data for that measure for that quarter. However, you must submit the aggregate population and sample size counts even if the population is zero. Leaving a field blank does not fulfill the requirement.

 

3. Report data on the Patient Experience of Care Survey

quarterly

Requirement

REQUIREMENT: 
Hospitals must report Patient Experience of Care Survey measures data.

Submission

SUBMISSION METHOD:
QualityNet Secure Portal

Deadline

DEADLINE:
Quarterly Submission Deadlines


Patient Experience of Care Survey measures

1. HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
2. CTM-3: 3-Item Care Transition Measure

 

Other considerations for the HCAHPS Survey

Hospitals with six or more HCAHPS-eligible discharges in a month must submit the total number of HCAHPS-eligible cases for the month as part of the quarterly survey data submission.

Hospitals with five or fewer HCAHPS-eligible discharges in a month are not required to submit the HCAHPS survey for that month.

If you have no HCAHPS-eligible discharges in a month, you must submit a zero for that month as a part of the quarterly data submission.

 

4. On an annual basis, Submit Four eCQMs 

eCQMs went through a serious reduction in 2020. They narrowed the list of available eCQMs down to eight.

MEASURE REMOVAL eCQMs

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

AMI-8a Primary PCI Received within 90 Minutes of Arrival
CAC-3 Home Management Plan of Care Given to Patient/Caregiver
EHDI-1a Hearing Screening Prior to Hospital Discharge
ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients
ED-2 Admit Decision Time to ED Departure Time for Admitted Patients
PC-01 Elective Delivery
PC-05 Exclusive Breast Milk Feeding
STK-02 Discharged on Antithrombotic Therapy
STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-05 Antithrombotic Therapy by End of Hospital Day Two
STK-06 Discharged on Statin Medication
STK-08 Stroke Education
STK-10 Assessed for Rehabilitation
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis
CMS506 Safe Use of Opioids – Concurrent Prescribing (NEW)

 


2020 eCQM Requirements

Requirement

REQUIREMENT: 
Hospitals must report on at least four of the available 8 eCQMs.

Submission

SUBMISSION METHOD:
QualityNet Secure Portal (Third party vendor authorization required.)

Deadline

DEADLINE:
February 29, 2020

 
 
AVAILABLE eCQMs 2020

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

ED-2 Admit Decision Time to ED Departure Time for Admitted Patients

1 Quarter of
CY 2020

March 1, 2021

PC-05 Exclusive Breast Milk Feeding
STK-2 Discharged on Antithrombotic Therapy
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-5 Antithrombotic Therapy by the End of Hospital Day Two
STK-6 Discharged on Statin Medication
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

 

Additional eCQM requirements

Your vendor/EHR must be certified to the 2015 Edition of Certified EHR Technology (CEHRT) for reporting in 2020. Your vendor/EHR must also be certified to for all eight eCQMs regardless of which eCQMs you submit.

All data must be submitted using the QRDA (Quality Reporting Document Architecture) Category 1 file format. File submission must include one QRDA 1 file per patient, per quarter that contains all episodes of care and the measures associated with the patient file.

Hospitals must use the most recent version of the eCQM specifications.

Hospitals must use a combination of factors to successfully complete their eCQM requirements. If you have at least five cases in the Initial Patient Population and have no zeros in your denominators for the measures you are submitting, you have successfully met the requirements for submission. If, however, you do not have at least five cases in the Initial Patient Population field, you must submit a Case Threshold Exemption form. If your measure has zero in the denominator you must submit a Zero Denominator Declaration form.

Other considerations for eCQM submission

By submitting your eCQMs to the IQR program, you will also successfully meet your CQM requirement for the Promoting Interoperability (Meaningful Use) program. 

 

5. On an annual basis, complete the DACA

Requirement

REQUIREMENT: 
Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).

Submission

SUBMISSION METHOD:
QualityNet Secure Portal

Deadline  DEADLINE:
Annual Submission Deadline between between April and mid-May of 2020.


The Data Accuracy and Completeness Acknowledgment (DACA) is a requirement for hospitals participating in the IQR program. The DACA is a method of electronically attesting that the data they submitted to the program is accurate and complete to the best of their knowledge. You can attest anytime between April and mid-May of 2020. Hospitals may complete the DACA within the QualityNet Secure Portal.

 

6. On an annual basis, Report One HAI measure

This category also went through significant changes for 2020. If you'll remember in our post about which measures are being retired, we explained that the Healthcare Associated Infection (HAI) measures were almost all removed from the IQR program but retained in both the Hospital Value-Based Purchasing and Hospital-Acquired Condition Reduction programs. Here's a look at how this category changes for next year.

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

CAUTI Catheter Associated Urinary Track Infections
CLABSI Central line Associated Blood Stream Infections
SSI Surgical Site Infection: Colon and Abdominal Hysterectomy
MRSA Methicillin-Resistant Staphylococcus Aureus Bacteremia
CDI Clostridium difficile
HCP Influenza Vaccination Coverage Among Healthcare Personnel (due to NHSN May 15)



2020 HAI Measure Requirements

That leaves just one measure for you to submit annually now: the Influence Vaccination measure.

Requirement

REQUIREMENT: 
Hospitals must report on one HAI measure.

Submission

SUBMISSION METHOD:
National Healthcare Safety Network (NHSN) Portal

Deadline  DEADLINE:
Annual Submission Deadline 
 

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

HCP Influenza Vaccination Coverage Among Healthcare Personnel (due to NHSN May 15)

Oct 1, 2019 to
Mar 31, 2020

May 18, 2020

 

 

7. Review your claims-Based Data

This next section looks complicated but only because there were so many measures removed.

In a nutshell hospitals will receive a score for their performance on 7 Claims-Based Outcome measures and 4 Claims-Based Payment Measures. No additional data submission is required to calculate the claims measure rates. CMS uses enrollment data, as well as Part A and Part B claims data, to calculate the measure rates.

Requirement

REQUIREMENT: 
Hospitals are evaluated for their performance on 7 Claims-Based Outcome measures and 4 Claims-Based Payment measures.

Submission

SUBMISSION METHOD:
No additional submission is required.

Deadline  DEADLINE:
No submission deadline
 

 Claims-Based Outcome measures

1. MORT-30-STK: Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Ischemic
2. READM-30-HWR: Hospital-Wide All-Cause Unplanned Readmission (HWR)
3. AMI Excess Days: Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction
4. HF Excess Days: Excess Days in Acute Care after Hospitalization for Heart Failure
5. PN Excess Days: Excess Days in Acute Care after Hospitalization for Pneumonia
6. COMP-HIP-KNEE (Hip/Knee Complications): Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
7. PSI 04: Death Rate Among Surgical Patients with Serious Treatable Complications
 

 Claims-Based Payment measures

1. AMI Payment: Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction
2. HF Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure (HF)
3. PN Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Pneumonia
4. THA/TKA Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Primary Elective Total Hip and/or Knee Arthroplasty

 

You will receive a Hospital-Specific Reports (HSRs) from CMS for these Claims-Based measures in the QualityNet Secure Portal. These reports contain discharge-level data, hospital-specific results and state and national results for comparison.

 

CLAIMS CATEGORY BREAKDOWN

MEASURE REMOVAL Claims-Based Patient Safety Measures

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

Hip/Knee Complications
(COMP-HIP-KNEE)

Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty
PSI-04 Death Rate among Surgical Inpatients with Serious Treatable Complications


The Hip/Knee Complications measure is still included in the Hospital VBP program and will continue to be reported on Hospital Compare.

AVAILABLE Claims-based Patient Safety Measures 2020

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

COMP-HIP-KNEE* Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty

April 1, 2017 through   March 31, 2020

N/A

PSI-04 Death Rate among Surgical Inpatients with Serious Treatable Complications

July 1, 2018 through
June 30, 2020

N/A


*Short Name for Hip and Knee Complication measure has been renamed from Hip/Knee Complications to COMP-HIP-KNEE effective FY 2022 Payment Determination. Note this will be the last year in which this measure is reported in the Hospital IQR Program.

MEASURE REMOVAL Claims-based Mortality Measures

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

MORT-30-COPD

Hospital 30-Day, All-Cause, Risk Standardized Mortality Rate Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization
MORT-30-PN Hospital 30-Day, All-Cause, Risk Standardized Mortality Rate Following Pneumonia Hospitalization
MORT-30-CABG Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Coronary Artery Bypass Graft (CABG) Surgery    
MORT-30-STK Hospital 30-Day, All-Cause, Risk Standardized Mortality Rate Following Acute Ischemic Stroke


Removed measures are included in the Hospital VBP program and will continue to be reported on Hospital Compare.

AVAILABLE Claims-based Mortality Measures 2020

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

MORT-30-STK Hospital 30-Day, All-Cause, Risk Standardized Mortality Rate Following Acute Ischemic Stroke

July 1, 2017 through
June 30, 2020

N/A

 


MEASURE REMOVAL
Claims-based Coordination of Care Measures

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

READM-30-HWR

Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) *
AMI Excess Days Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction
HF Excess Days Excess Days in Acute Care after Hospitalization for Heart Failure ✓ 
PN Excess Days Excess Days in Acute Care after Hospitalization for Pneumonia


*The Hospital-Wide All-Cause Unplanned Readmission claims measure will be replaced with the Hybrid Hospital-Wide Readmission measure beginning with FY 2026 payment.

aVAILABLE Claims-based Coordination of Care Measures 2020

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

READM-30-HWR** Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)

July 1, 2019 to
June 30, 2020

N/A

AMI Excess Days Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction

July 1, 2017 to
June 30, 2020

N/A

HF Excess Days Excess Days in Acute Care after Hospitalization for Heart Failure

July 1, 2017 to
June 30, 2020

N/A

PN Excess Days Excess Days in Acute Care after Hospitalization for Pneumonia

July 1, 2017 to
June 30, 2020

N/A


** FY 2020 Final Rule decision to remove Hospital-Wide All-Cause Unplanned Readmission and replacing it with NQF #2879 Hybrid Hospital-Wide Readmission measure beginning with FY 2026 Payment.


NEW Hybrid Measure REQUIREMENT

CMS has released the new Hybrid Hospital Wide Readmission Measure to replace the Claims-Based Hospital-Wide All-Cause Unplanned Readmission Measure (HWR). In the most recent final rule, CMS decided that the Hybrid HWR measure will be voluntary starting in 2021 and mandatory beginning in 2023. This data will be reported on Hospital Compare in 2025. 

Read Also: The Hybrid Readmission Measure: Understanding How it Works

TIMELINE
FIRST VOLUNTARY SUBMISSION: Begins for discharges July 1, 2021 through June 30, 2022.
SECOND VOLUNTARY SUBMISSION: Begins for discharges July 1, 2022 through June 30, 2023. FIRST MANDATORY REPORTING PERIOD: Applies to discharges July 1, 2023 through June 30, 2024 for FY 2026 payment determination.
 
OTHER CONSIDERATIONS

• Submissions would be required no later than the first business day 3 months following the end of the reporting period
• Validation processes not yet established (expected in future rulemaking)
• Results for first mandatory submission will be posted on Hospital Compare July 2025
• Updated electronic specifications for the first voluntary submission period to be published in the Spring of 2020 (note it is likely these specifications will change slightly from the previously posted specifications on https://www.qualitynet.org/inpatient/measures/hybrid/resources)

MEASURE REMOVAL Claims-based Payment Measures

Short
Name

Measure
Name 

FY 2020 Payment

FY 2021 Payment

FY 2022 Payment

FY 2023 Payment

AMI Payment

Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI)
HF Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure (HF)
PN Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Pneumonia ✓ 
THA/TKA Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Primary Elective Total Hip and/or Knee Arthroplasty

 

AVAILABLE Claims-based Payment Measures

Short Name

Measure
Name 

Discharge Dates for Data Collection

Data Submission
Deadlines

AMI Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI)

July 1, 2016 to
June 30, 2019

N/A

HF Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure (HF)

July 1, 2016 to
June 30, 2019

N/A

PN Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Pneumonia

July 1, 2016 to
June 30, 2019

N/A

THA/TKA Payment Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Primary Elective Total Hip and/or Knee Arthroplasty

April 1, 2017 to
March 31, 2020

N/A

 

8. Fulfill Validation/Audit Requirements if selected

CMS will continue conducting audits for both chart-abstracted measures and eCQMs next year.

Chart-abstracted audits

CMS performs random and targeted provider audits of hospitals participating in the IQR program. To successfully pass the audit, hospitals must receive a 75% score or better. 

If you are audited for your 2018 chart-abstracted submission, it contained data from Q3 2017, Q4 2017, Q1 2018 and Q2 2018. CMS will validate up to eight cases for clinical process of care measures (STK, ED, IMM, VTE or SEP) and up to 10 candidate HAI cases (up to four candidate HAI per template and up to two candidate SSI cases) per quarter per hospital.

Hospitals are also required to submit either:
MRSA & CDI Validation Templates OR CLABSI & CAUTI Validation Templates

Each quarter the CDAC will send hospitals a request to submit a patient medical record for each case and candidate case that CMS selected to be audited.

eCQM audits

CMS will select 200 hospitals to audit via random sample. Eight cases (individual patient-level reports) will be selected from the QRDA 1 files that were submitted. The hospital must then submit at least 75% of sample eCQM medical records within 30 days of the request. The eCQM data submitted must contain sufficient patient-level information including arrival date and time, inpatient admission date and discharge data from the inpatient episode of care.

Hospitals who were selected for chart-abstracted audits or hospitals granted an extraordinary circumstances exception will be excluded from the eCQM audit.

 

Getting Quality Management Help

Medisolv has worked with many hospitals from the very beginning of their quality improvement process. We’ve felt their frustration and understand their concerns. But we can assure you that we can get you through this process and provide long-term support as the regulations and requirements change.

Not making a plan is still a plan, but not a sustainable one. Yearly penalty assessments will become steeper and accumulate.

Medisolv’s ENCOR Quality Reporting and Management software solution provides hospitals with the tools they need to meet all the CMS IQR reporting requirements. ENCOR was ranked #1 in Quality Management in the 2019 Best in KLAS report.

In addition to the software, our solution provides your hospital with expert clinical consultants that will guide your hospital through implementation, validation and submission. Unlike other companies, we do the heavy lifting for you when it comes to submission.

Learn about ENCOR >>



FREE DOWNLOAD:

2020 Hospital IQR Program Requirements eBook 

Ensure a smooth and stress-free submission to the Hospital Inpatient Quality Reporting (IQR) program. Download the 2020 IQR Program Requirements eBook, which includes all you need to know to successfully complete the program in 2020. 

2020-IQR-eBook_Image_MockupThis guide includes:

  1. Requirements for each part of the program
  2. Submission method details
  3. A measure removal guide for 2019-2021
  4. 2020 deadlines

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Erin Heilman

Erin Heilman

Erin Heilman is the Marketing Director for Medisolv, Inc.

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