2022 Hospital IQR Requirements

If it's September, it's time for you and your quality department to start preparing for the next year’s Hospital Inpatient Quality Reporting (IQR) program requirements. Here, we’ll give you a quick review of the IQR program, summarize key 2022 requirements and detail the quality measures that you’ll be required to submit to CMS.

A short IQR primer

The IQR program dates back to 2003, when it was mandated by the Medicare Prescription Drug, Improvement, and Modernization Act, better known as the MMA. A provision in the MMA enabled CMS to reward or penalize hospitals and health systems based on how well they report quality measures to CMS. In turn, CMS can publish those measures to help consumers decide which hospitals to go to for their care. Rewards and penalties come in the form of increases or decreases in the rates Medicare pays hospitals for care to Medicare beneficiaries.

Since then, provisions in other federal laws—including the Deficit Reduction Act of 2005, the American Recovery and Reinvestment Act of 2009 and the Patient Protection and Affordable Care Act of 2010—have built the IQR into what it is today, and that's the foundation that supports all other performance-based Medicare payment programs affecting hospitals. 

All acute-care hospitals that CMS has certified to be eligible to treat Medicare patients also are eligible to join the IQR program, which is voluntary. But CMS automatically reduces Medicare payment rates by 25% to eligible hospitals who don't meet the requirements below, making IRQ participation practically mandatory for most quality leaders.  

Summary of Changes to the IQR requirements

Below is a summary of the changes in IQR requirements, some of which take effect as soon as Oct. 1.

The changes in reporting requirements fall into three categories: new measures, discontinued measures and updates to existing EHR certification criteria.

New Measures

• Maternal Morbidity structural measure (Reporting period: Oct. 1–Dec. 31, 2021)
• COVID-19 Vaccination Coverage Among Health Care Personnel measure (Reporting period: Oct. 1–Dec. 31, 2021)
• Hybrid Hospital-Wide All-Cause Risk Standardized Mortality measure (voluntary reporting starts July 1 2022, and mandatory reporting starts July 1, 2023)
• Hospital Harm—Severe Hypoglycemia eCQM (available Jan. 1, 2023)
• Hospital Harm—Severe Hyperglycemia eCQM (available Jan. 1, 2023)

Discontinued Measures

• Exclusive Breast Milk Feeding measure (discontinued Jan. 1, 2024)
• Admit Decision Time to Emergency Department Departure Time for Admitted Patients measure (discontinued Jan. 1, 2024)
• Discharged on Statin Medication eCQM (discontinued Jan. 1, 2024)

Updates to Existing EHR Certification Criteria

• Hospitals must use certified EHR technology that's up to date with the 2015 Edition Cures Update and supports the reporting requirements for all available eCQMs (effective Jan. 1, 2023)

2022 IQR Requirements Summary

These mandatory requirements are due quarterly:

1. Submit two chart-abstracted measures 
2. Submit population and sampling numbers (for chart-abstracted measures only)
3. Submit HCAHPS survey data

These mandatory requirements are due annually:

1. Submit four eCQMs
2. Complete the Data Accuracy and Completeness Acknowledgement (DACA)
3. Submit two healthcare-associated infection (HAI) measures

You must also:

1. Regularly review your claims-based data

1. On an Annual Basis, Submit Three Quarters of Data for Four eCQMs

eCQM requirements have been ramped up over the next couple of years. In 2022, you must submit three quarters instead of two quarters this year. By 2023, you must submit a full year of eCQM data.

One of the eCQMs you submit for 2022 MUST be the Opioid eCQM. 

As you know, starting this year, CMS publicly reports your eCQM performance on Care (Hospital) Compare.

2022 eCQM Requirements

	REQUIREMENT: Hospitals must report three quarters of data for at least four of the available nine eCQMs. Hospitals MUST submit the Opioid eCQM as one of their four eCQMs.
	SUBMISSION METHOD: QualityNet Secure Portal (third-party vendor authorization required)
	DEADLINE: February 28, 2023

Additional eCQM requirements

Your vendor/EHR must be certified to the 2015 Edition of Certified EHR Technology (CEHRT) for reporting in 2022. Your vendor/EHR must also be certified to for all nine 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 on QRDA one 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.

2. Submit Two Chart-Abstracted Measures Quarterly

CMS did not make any changes to the 2022 chart-abstracted measure requirements.

2022 Chart Abstracted Measure Requirements

	REQUIREMENT: Hospitals must report on two chart-abstracted measures.
	SUBMISSION METHOD: QualityNet Secure Portal (third-party vendor required)
	DEADLINE: Quarterly Submission Deadlines

 

SHORT NAME	MEASURE NAME
PC-01	Elective Delivery
Sepsis	Severe Sepsis and Septic Shock

 

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.

3. 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 required)
	DEADLINE: Quarterly Submission Deadlines

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 requirements.

4. Report HCAHPS Data Quarterly

	REQUIREMENT: Hospitals must report Patient Experience of Care Survey measures data.
	SUBMISSION METHOD: QualityNet Secure Portal
	DEADLINE: Quarterly Submission Deadlines

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.

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

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 1 - May 15, 2023. Hospitals may complete the DACA within the QualityNet Secure Portal.

6. On an Annual Basis, Report Two HAI Measures

This year, thanks to the pandemic, the big change to this category was the addition of the HCP COVID-19 Vaccination measure. That makes two measures for you to submit annually in this category.

2022 HAI Measure Requirements

	REQUIREMENT: Hospitals must report on two HAI measures.
	SUBMISSION METHOD: National Healthcare Safety Network (NHSN) Portal
	DEADLINE: Annual Submission Deadline

7. Review Your Claims-Based Data

Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment.

	REQUIREMENT: Hospitals are evaluated for their performance on 10 Claims-Based measures in four categories.
	SUBMISSION METHOD: No additional submission is required
	DEADLINE: No Submission Deadline

Claims-Based Measures by Category

Claims-Based Patient Safety Measures for 2022

Claims-Based Mortality Measures for 2022

Claims-Based Coordination of Care Measures for 2022

Claims-Based Payment Measures for 2022

*CMS is replacing the Hospital-Wide All-Cause Unplanned Readmission claims measure with the new Hybrid Hospital-Wide Readmission measure. The two-year voluntary submission phase of the hybrid measure began on July 1, 2021. Mandatory submission of both hybrid measures begins on July 1, 2023.

2022 IQR Next Steps

Now that you know what to do, it's time to put your 2022 IQR plan into action. We can help.

Medisolv works with leading hospitals and health systems across the country to organize, update, simplify and streamline their IQR program reporting and compliance processes. Medisolv's ENCOR Quality Reporting and Management software platform can give you the tools you need to meet all your IQR requirements and maximize your reimbursement from Medicare now and in the future.

We'll be following up this blog post with more reporting and client education as key CMS IQR deadlines hit through the end of the year and into 2022.

• To learn more about these changes, please read "2022 IQR & PI Program Changes: A Summary from the IPPS Rule" on medisolv.com.
• Here's a fact sheet from CMS on the 2022 IQR requirements included in the final IPPS rule.
• And if you really want to get into the weeds, you can visit CMS' FY 2022 IPPS Final Rule Home Page. 

Download our 2022 IQR Program Requirements eBook:

This eBook includes:

1. The requirements for each part of the program
   1. Abstracted, eCQMs, DACA, HCAHPS, HAI, Claims
2. Submission method details
3. 2022 deadlines