2023 Hospital IQR Requirements

It’s time 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 2023 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 program 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 IQR participation practically mandatory for most quality leaders.  

Summary of changes to the IQR requirements

Below is a summary of the changes in IQR requirements in two categories: new measures and requirements and discontinued measures.

New Measures & Requirements

• Medicare Spending Per Beneficiary (MSPB) hospital claims measure (readopted for fiscal year 2024)
• Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total THA/TKA claims measure (readopted for fiscal year 2024)
• Hospital Commitment to Health Equity structural measure (required reporting year 2023)
• Severe Obstetric Complications eCQM (required reporting year 2024)
• Cesarean Birth eCQM (required reporting year 2024)
• Screening for Social Drivers of Health process measure (required reporting year 2024)
• Screen Positive Rate for Social Drivers of Health process measure (required reporting year 2024)
• Hospital-Level, Risk Standardized Patient-Reported Outcomes Performance Measure (PRO-PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (required reporting year 2025)
• Hospital-Harm—Opioid-Related Adverse Events eCQM
• Global Malnutrition Composite Score eCQM

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)

2023 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
4. Submit one healthcare-associated infection (HAI) measure (COVID-19 Immunization)

These mandatory requirements are due annually:

1. Submit four eCQMs
2. Submit two hybrid measures
3. Submit two structural measure
4. Complete the Data Accuracy and Completeness Acknowledgement (DACA)
5. Submit one healthcare-associated infection (HAI) measure (Influenza Immunization)

You must also:

1. Regularly review your claims-based data

1. Submit four eCQMs annually

eCQM requirements have been ramped up over the next couple of years. In 2023, you must submit four quarters (a full year) instead of three quarters.

One of the eCQMs you submit for 2023 MUST be the Safe Use of Opioids eCQM.

CMS will publicly report your eCQM performance on Care Compare.

	REQUIREMENT: Hospitals must report four quarters of data for at least four of the available 13 eCQMs. Hospitals MUST submit the Safe Use of Opioids eCQM as one of their four eCQMs.
	SUBMISSION METHOD: QualityNet Secure Portal (third-party vendor authorization required)
	DEADLINE: February 29, 2024

*These are anticipated submission dates based on previous years. CMS has not officially released these submission dates.

Additional eCQM requirements

Your vendor/EHR must be certified to the 2015 Cures Edition of Certified EHR Technology (CEHRT) for reporting in 2023. Your vendor/EHR must also be certified to for all 13 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 eCQM requirements for the Promoting Interoperability (Meaningful Use) program.

2. Submit two hybrid measures annually

	REQUIREMENT: Hospitals must report four quarters of data for the two hybrid measures.
	SUBMISSION METHOD: QualityNet Secure Portal (third-party vendor authorization required)
	DEADLINE: September 30, 2024

 

SHORT NAME	MEASURE NAME	DISCHARGE DATES	SUBMISSION DEADLINE
Hybrid HWR	Required: Hybrid Hospital-Wide All-Cause Readmission Measure	July 1, 2023-June 30, 2024	September 30, 2024
Hybrid HWM	Required: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure

 

Additional hybrid measure requirements

Hybrid measures are unlike eCQMs in the fact that they combine electronic data with claims data. The submission we are referencing here is one half of the hybrid measure calculation. The hybrid measure file is a QRDA I file (just like an eCQM) but contains Core Clinical Data Elements (CCDEs) and Linking Variables for CMS to connect the clinical data with the claims data.

For more information about hybrid submissions, read our post about Prepping for Hybrid Measure Submissions.

CMS will publicly report your hybrid measure performance on Care Compare.

 

3. Submit two chart-abstracted measures quarterly

CMS did not make any changes to the 2023 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	DISCHARGE DATES	SUBMISSION DEADLINE
PC-01	Elective Delivery	Q1 2023 Q2 2023 Q3 2023 Q4 2023	8/15/2023* 11/15/2023* 2/15/2024* 5/15/2024*
Sepsis	Severe Sepsis and Septic Shock: Management Bundle (Composite Measure)	Q1 2023 Q2 2023 Q3 2023 Q4 2023	8/15/2023* 11/15/2023* 2/15/2024* 5/15/2024*

*These are anticipated submission dates based on previous years. CMS has not officially released these submission dates.

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.

4. Submit population and sample size data quarterly

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.

5. Submit two structural measure annually

	REQUIREMENT: Hospitals must submit two structural measure.
	SUBMISSION METHOD: QualityNet Secure Portal
	DEADLINE: Annual Submission Deadlines

*These are anticipated submission dates based on previous years. CMS has not officially released these submission dates.

CMS has established a new designation reported on Care Compare for those who attest "yes" to the Maternal Morbidity structural measure. These hospitals will be noted as a “Birthing-Friendly” facility on Care Compare.

6. Report HCAHPS data quarterly

CMS did not make any changes to the 2023 HCAHPS measure requirements.

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

*These are anticipated submission dates based on previous years. CMS has not officially released these submission dates.

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.

7. On an annual basis, complete the DACA

CMS did not make any changes to the 2023 DACA requirements.

	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, 2024. Hospitals may complete the DACA within the QualityNet Secure Portal.

8. Report two HAI measures

	REQUIREMENT: Hospitals must report on two HAI measures.
	SUBMISSION METHOD: National Healthcare Safety Network (NHSN) Portal
	DEADLINE: Influenza Vaccination Annual Submission Deadline COVID-19 Vaccination Quarterly Submission Deadline

*These are anticipated submission dates based on previous years. CMS has not officially released these submission dates.

9. Review your claims-based data

Hospitals will receive a score for their performance on 12 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment.

	REQUIREMENT: Hospitals are evaluated for their performance on 12 Claims-Based measures in four categories.
	SUBMISSION METHOD: No additional submission is required
	DEADLINE: No Submission Deadline

Claims-Based Patient Safety Measures 

Claims-Based Mortality Measures 

Claims-Based Coordination of Care Measures 

*CMS is replacing the Hospital-Wide All-Cause Unplanned Readmission claims measure with the new Hybrid Hospital-Wide Readmission measure beginning on July 1, 2023.

Claims-Based Payment Measures 

Voluntary Reporting of Process Measures

In 2023, you may voluntarily report the two Social Drivers of Health measures before they are required in 2024.

2023 IQR Next Steps

Now that you know what to do, it's time to put your 2023 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 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 2023.

• To learn more about these changes, please read 2023 IQR Program Changes: A Summary from the Final Rule
• Here's a fact sheet from CMS on the 2023 IQR requirements included in the final IPPS rule.
• And if you really want to get into the weeds, you can read CMS’s FY 2023 IPPS Final Rule.