2020 Hospital IQR Program Requirements

Is your hospital ready for hospital quality reporting in 2020? I know it seems a little early, but when it comes to successfully fulfilling regulatory reporting requirements, it’s never too soon to start preparing.

Requirement changes in response to COVID-19 are reflected below.

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. 

*ED-2 is being retained as an electronic measure.

2020 Chart Abstracted Measure Requirements

Here is your work for 2020.

	REQUIREMENT:  Hospitals must report on two chart-abstracted measures.
	SUBMISSION METHOD: QualityNet Secure Portal (Third party vendor authorization required.)
	DEADLINE: Quarterly Submission Deadlines In response to COVID-19, hospitals do not need to submit Q1 & Q2 chart-abstracted measures.

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 Data Quarterly

	REQUIREMENT:  Hospitals must submit population and sampling numbers for all chart-abstracted measures.
	SUBMISSION METHOD: QualityNet Secure Portal (Third party vendor authorization required.)
	DEADLINE: Quarterly Submission Deadlines In response to COVID-19, hospitals do not need to submit Q1 & Q2 population and sample size data.

*Data submission for these quarters is optional.

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 HCAHPS Data Quarterly

	REQUIREMENT:  Hospitals must report Patient Experience of Care Survey measures data.
	SUBMISSION METHOD: QualityNet Secure Portal
	DEADLINE: Quarterly Submission Deadlines In response to COVID-19, Q1 & Q2 data submission is optional.

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. Also notable, they added a brand-new eCQM: Safe Use of Opioids - Concurrent Prescribing.

MEASURE REMOVAL eCQMs

2020 eCQM Requirements

	REQUIREMENT:  Hospitals must report on at least four of the available 8 eCQMs.
	SUBMISSION METHOD: QualityNet Secure Portal (Third party vendor authorization required.)
	DEADLINE: March 1, 2021 No changes due to COVID-19.

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:  Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).
	SUBMISSION METHOD: QualityNet Secure Portal
	DEADLINE: Annual Submission Deadline between between April 1 - May 15, 2021. No changes due to COVID-19.

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 2021. Hospitals may complete the DACA within the QualityNet Secure Portal.

*Note: You are not required to submit the 2019 DACA in 2020.

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.

2020 HAI Measure Requirements

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

	REQUIREMENT:  Hospitals must report on one HAI measure.
	SUBMISSION METHOD: National Healthcare Safety Network (NHSN) Portal
	DEADLINE: Annual Submission Deadline  In response to COVID-19, hospitals do not need to submit the 2019-2020 reporting period data. Hospitals must still submit the 2020-2021 reporting period data.

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:  Hospitals are evaluated for their performance on seven Claims-Based Outcome measures and four Claims-Based Payment measures.
	SUBMISSION METHOD: No additional submission is required.
	DEADLINE: No submission deadline. In response to COVID-19, Q1 & Q2 data will not be used for performance or payment.

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.

• 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

AVAILABLE Claims-Based Payment Measures

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.

*Note: Due to COVID-19 Q1 & Q2 abstracted measure audits do not need to be submitted.

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. 

This guide includes: Updated requirements for each part of the program based on COVID-19 changes Submission method details A measure removal guide for 2019-2021 2020 deadlines