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2020 Reporting Requirements for the CMS IQR Program

There are essentially seven requirements you must fulfill to successfully complete the IQR program in 2020. Due to the COVID-19 pandemic, there are a few changes to the program.

We've created a summary video for you to watch and confirm your understanding of what you need to do this year. You'll need eight minutes to watch this video, ten minutes if you want to take notes.

You can print out our eBook guide if you'd like to make physical notes while watching. And if you prefer the transcript, the written text is below. Learn how you learn best.

 

1. Submit Two Chart-Abstracted Measures Quarterly

Hospitals must report on the two chart-abstracted measures listed below. Hospital data must be submitted using the QualityNet Secure Portal.

Please note that due to the COVID-19 pandemic, CMS has made it optional to submit data for Quarter 1 and Quarter 2.

Also read: Changes to Quality Reporting in Response to COVID-19

Short Name

Measure Name 

Submission Deadlines

PC-01 Elective Delivery
(Web-based Measure)

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)
 
*Data submission for these quarters is optional.

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

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

Just remember, Q1 & Q2 data is optional to submit during this period.

Short Name

Measure Name 

Submission Deadlines

PC-01 Elective Delivery
(Web-based Measure)

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)


*Data submission for these quarters is optional.

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

Hospitals must report Patient Experience of Care Survey measures data, otherwise known as HCAHPS. The submission method is still the QualityNet Secure Portal and it’s still a quarterly submission deadline.

Once again, due to the COVID-19 pandemic, Q1 and Q1 data submission is optional.

Patient Experience of Care Survey Measures

HCAHPS: Hospital Consumer Assessment of Healthcare Providers and Systems
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 

For 2020, Hospitals must continue to submit four of the available eight eCQMs to the IQR program. You must submit any one quarter of 2020 data. The deadline for submission is March 1, 2021 and the submission method is via the QualityNet Secure portal.

Name

Measure Name 

Submission Deadline

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

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, which as of this post is May 2019.

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

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.

6. On an Annual Basis, Report One HAI Measure

The sixth requirement, report HAI measures, went through significant changes for 2020. CMS has removed five of the six available measures from the IQR program, however, you still must report those removed measures in the Hospital Value-Based Purchasing and Hospital-Acquired Condition Reduction programs.

That leaves just one measure for you to submit annually now to the IQR program: the Influenza Vaccination measure. This measure is submitted annually via the National Healthcare Safety Network or NHSN portal.

Measure Name 

Submission Deadline

HCP
Influenza Vaccination Coverage Among Healthcare Personnel (submission through NHSN)

May, 2021

 

7. Review your Claims-Based Data

For the IQR program, hospitals are evaluated on their performance on seven Claims-Based Outcome measures and four Claims-Based Payment measures.

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 from CMS for these Claims-Based measures. These reports contain discharge-level data, hospital-specific results and state and national results for comparison. As a best practice you should be monitoring your hospital’s performance on these measures throughout the year.

Please note, due to the COVID-19 pandemic, CMS will not consider Q1 & Q2 claims data.

New Hybrid Measure 

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. 

Also read: 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.

 

 

 

Focus on Quality

We've seen some big changes in the way Quality measures are captured and reported over the years. With Medisolv as your partner you are guided through every new change along the way. Talk with us about how we can help you track and improve your quality performance on measures like the newest eCQM Safe Use of Opioids.

Here are some additional resources you may find useful.

 

 

Erin Heilman

Erin Heilman is the Marketing Director for Medisolv, Inc.

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