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      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.

      Requirements-Icon-01 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-01 SUBMISSION METHOD:
      QualityNet Secure Portal (third-party vendor authorization required)
      Submission-Deadline DEADLINE:
      February 29, 2024

       

      SHORT NAME MEASURE NAME DISCHARGE DATES SUBMISSION DEADLINE
      OPI-1 Required: Safe Use of Opioids – Concurrent Prescribing Any four quarters
      of CY 2023
      February 29, 2024*
      PC-02 Cesarean Birth
      PC-05 Exclusive Breast Milk Feeding
      PC-07 Severe Obstetric Complications
      HH-01 Hospital Harm – Severe Hypoglycemia
      HH-02 Hospital Harm – Severe Hypoglycemia
      STK-02 Discharged on Antithrombotic Therapy
      STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter
      STK-05 Antithrombotic Therapy by the End of Hospital Day Two
      STK-06 Discharged on Statin Medication
      VTE-1 Venous Thromboembolism Prophylaxis
      VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

      ED-2

      Admit Decision Time to ED Departure Time for Admitted Patients

      *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

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must report four quarters of data for the two hybrid measures.
      Submission-Method-01 SUBMISSION METHOD:
      QualityNet Secure Portal (third-party vendor authorization required)
      Submission-Deadline 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.

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must report on two chart-abstracted measures.
      Submission-Method-01 SUBMISSION METHOD:
      QualityNet Secure Portal (third-party vendor required)
      Submission-Deadline 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

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must submit population and sampling numbers for all chart-abstracted measures.
      Submission-Method-01 SUBMISSION METHOD:
      QualityNet Secure Portal (third-party vendor required)
      Submission-Deadline DEADLINE:
      Quarterly Submission Deadlines

      SHORT NAME MEASURE NAME DISCHARGE DATES SUBMISSION DEADLINE
      PC-01 Elective Delivery

      Q1 2023
      Q2 2023
      Q3 2023
      Q4 2023

      8/1/2023*
      11/1/2023*
      2/1/2024*
      5/1/2024*

      Sepsis Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) Q1 2023
      Q2 2023
      Q3 2023
      Q4 2023
      8/1/2023*
      11/1/2023*
      2/1/2024*
      5/1/2024*

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

      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

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must submit two structural measure.
      Submission-Method-01 SUBMISSION METHOD:
      QualityNet Secure Portal
      Submission-Deadline DEADLINE:
      Annual Submission Deadlines

       

      SHORT NAME MEASURE NAME DATES SUBMISSION DEADLINE
      Maternal Morbidity Maternal Morbidity Structural Measure

      January 1, 2023 – December 31, 2023

      May 15, 2024*

      HCHE Hospital Commitment to Health Equity 

      January 1, 2023 – December 31, 2023

      TBD

      *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.

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must report Patient Experience of Care Survey measures data.
      Submission-Method-01 SUBMISSION METHOD:
      QualityNet Secure Portal
      Submission-Deadline DEADLINE:
      Quarterly Submission Deadlines

       

      SHORT NAME MEASURE NAME DISCHARGE
      DATES
      SUBMISSION DEADLINE
      HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems

      Q1 2023
      Q2 2023
      Q3 2023
      Q4 2023

      7/5/2023*
      10/4/2023*
      1/3/2024*
      4/3/2024*

      CTM-3 3-Item Care Transition Measure Q1 2023
      Q2 2023
      Q3 2023
      Q4 2023
      7/5/2023*
      10/4/2023*
      1/3/2024*
      4/3/2024*

      *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.

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).
      Submission-Method-01 SUBMISSION METHOD:
      QualityNet Secure Portal 
      Submission-Deadline 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

      Requirements-Icon-01 REQUIREMENT:
      Hospitals must report on two HAI measures.
      Submission-Method-01 SUBMISSION METHOD:
      National Healthcare Safety Network (NHSN) Portal
      Submission-Deadline DEADLINE:

      Influenza Vaccination Annual Submission Deadline
      COVID-19 Vaccination Quarterly Submission Deadline 

       

      SHORT NAME MEASURE NAME DISCHARGE DATES SUBMISSION DEADLINE
      HCP Influenza Vaccination Influenza Vaccination Coverage Among Healthcare Personnel Oct. 1, 2022- March 31, 2023 May 15, 2023*
      HCP COVID-19 Vaccination COVID-19 Vaccination Coverage Among Healthcare personnel

      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.

      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.

      Requirements-Icon-01 REQUIREMENT:
      Hospitals are evaluated for their performance on 12 Claims-Based measures in four categories.
      Submission-Method-01 SUBMISSION METHOD:
      No additional submission is required
      Submission-Deadline DEADLINE:
      No Submission Deadline 

       

      Claims-Based Patient Safety Measures 

      SHORT NAME MEASURE NAME
      CMS PSI-04 Death Rate Among Surgical Inpatients with Serious Treatable Complications

       

      Claims-Based Mortality Measures 

      SHORT NAME MEASURE NAME
      MORT-30-STK Hospital 30-Day, All-Cause, Risk Standardized-Mortality Rate Following Acute Ischemic Stroke
      COMP-HIP-KNEE Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary THA and/or TKA

       

      Claims-Based Coordination of Care Measures 

      SHORT NAME MEASURE NAME
      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

       

      Claims-Based Payment Measures 

      SHORT NAME MEASURE NAME
      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 an Episode-of-Care for Primary Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty
      MSPB Medicare Spending Per Beneficiary (MSBP) - Hospital

      *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.

      Voluntary Reporting of Process Measures

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

       

      SHORT NAME MEASURE NAME DISCHARGE DATES SUBMISSION DEADLINE
      SDOH-01

      Screening for Social Drivers of Health

      January 1, 2023 - December 31, 2023
      TBD
      SDOH-02

      Screen Positive Rate for Social Drivers of Health

       

      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.

       

      Medisolv Can Help

      This is a big year for Quality. Medisolv can help you along the way. Along with award-winning software you receive a consultant that helps you with all of your technical and clinical needs.

      We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.

      • We help troubleshoot technical and clinical issues to improve your measures.
      • We keep you on track for your submission deadlines and ensure you don’t miss critical dates
      • We help you select and set up measures that make sense based on your hospital’s situation.
      • You receive one consultant that you can call anytime with questions or concerns. 

      Contact us today.

       
      Erin Heilman

      Erin Heilman is the Vice President of Sales & Marketing for Medisolv, Inc.

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