2024 Hospital IQR Requirements

It’s time for quality teams like yours to start studying up on the 2024 Hospital Inpatient Quality Reporting (IQR) program requirements.

As always, Medisolv is here to help with everything you need to prepare, including a quick review of the IQR program, a summary of your key 2024 IQR requirements, and a step-by-step guide to the quality measures that you’ll be required to submit to the Centers for Medicare and Medicaid Services (CMS) in Reporting Year 2024 for Fiscal Year (FY) 2026 results. Your 2024 IQR study hall is now in session.

A Quick IQR History Lesson

Created in 2003 as a mandate under the Medicare Prescription Drug, Improvement, and Modernization Act (better known as the MMA), the IQR program enables CMS to reward or penalize hospitals and health systems based on how well they report and perform on quality measures. Rewards and penalties come in the form of increases or decreases in the rates Medicare pays hospitals for care to Medicare beneficiaries. At the same time, CMS can publish hospitals’ measure results as a means of helping consumers choose which hospitals to go to for their care.

Over the last 20 years, the IQR program has grown and evolved under 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—to become the cornerstone of all other performance-based Medicare payment programs for hospitals like yours. 

Technically, the IQR program is voluntary. But here’s the kicker: Hospitals that fail to meet the following requirements will have their Annual Payment Update (APU) reduced by 25% through the automatic reduction of Medicare payment rates by the CMS.Thus, IQR participation is practically mandatory for any hospital that wants to remain sustainable. So, with that being said, let’s move on to your 2024 IQR program requirements.

Summary of Changes to the IQR Requirements

NEW: Mandatory eCQMs

1. PC-02: Cesarean Birth
2. PC-07: Severe Obstetric Complications

NEW: Available eCQMS

1. HH-ORAE: Hospital-Harm—Opioid-Related Adverse Events
2. GMCS: Global Malnutrition Composite Score

NEW: Mandatory Process Measures

1. SDOH-01: Screening for Social Drivers of Health
2. SDOH-02: Screen Positive Rate for Social Drivers of Health

NEW: THA/TKA PRO-PM

CMS has introduced the IQR program’s first Patient-Reported Outcome-Based Performance Measure (PRO-PM) on a voluntary basis. Data collection for mandatory reporting begins on April 2, 2024.

1. THA/TKA PRO-PM: Hospital-Level Total Hip Arthroplasty/Total Knee Arthroplasty Patient-Reported Outcome-Based Performance Measure

RETIRED: eCQMs

All three measures will be officially discontinued on January 1, 2024.

1. PC-05: Exclusive Breast Milk Feeding
2. ED-02: Median Admit Decision Time to Emergency Department Departure Time for Admitted Patients
3. STK-06: Discharged on Statin Medication

RETIRED: Chart-Abstracted Measures

1. PC-01: Elective Delivery

RETIRED: Claims Measures

On July 1, 2023, CMS officially replaced this claims measure with the Hybrid Hospital-Wide Readmission (HWR) measure.

1. READM-30-HWR: Hospital-Wide All-Cause Unplanned Readmission Measure

2024 IQR Requirements Summary

These mandatory requirements are due quarterly:

1. Submit one chart-abstracted measure
2. Submit population and sampling numbers (for your chart-abstracted measure only)
3. Submit HCAHPS survey data
4. Submit the COVID-19 Immunization healthcare-associated infection (HAI) measure

These mandatory requirements are due annually:

1. Submit six eCQMs (three required + three self-selected)
2. Submit two hybrid measures
3. Submit two process measures
4. Submit two structural measures
5. Complete the Data Accuracy and Completeness Acknowledgement (DACA)
6. Submit the Influenza Immunization healthcare-associated infection (HAI) measure

 You must also:

1. Regularly review your claims-based data 
2. Begin collecting pre-op data for the upcoming THA/TKA PRO-PM requirement

1. Submit Six eCQMs Annually

You’ll have more eCQM requirements than ever before in 2024. While you get to choose three of your eCQMs, there are three eCQMS that you MUST submit: Safe Use of Opioids, Cesarean Birth, and Severe Obstetric Complications.

Just like in 2023, you must submit four quarters (a full year) of data for your eCQMs.

CMS will publicly report your eCQM performance on Care Compare.

	REQUIREMENT: Hospitals must report four quarters of data for at least six of the available eCQMs. Hospitals MUST submit the Safe Use of Opioids, Cesarean Birth, and Severe Obstetric Complications eCQMs as three of their six eCQMs.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: February 28, 2025

*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 2024. Your vendor/EHR must also be certified to for all 12 eCQMs regardless of which eCQMs you submit.

All data must be submitted using the QRDA (Quality Reporting Document Architecture) Category 1 file format (QRDA I). File submission must include one QRDA I 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 (PI) program.

2. Submit Two Hybrid Measures Annually

	REQUIREMENT: Hospitals must report four quarters of data for the two hybrid measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: September 30, 2025

 

SHORT NAME	MEASURE NAME	DISCHARGE DATES	SUBMISSION DEADLINE
Hybrid HWR	Required: Hybrid Hospital-Wide All-Cause Readmission Measure	July 1, 2024- June 30, 2025	September 30, 2025*
Hybrid HWM	Required: Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure

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

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.

Starting July 1, 2024, both hybrid measures will include Medicare Advantage beneficiaries in addition to the current Fee For Service (FFS) Medicare beneficiaries.

For more information about hybrid submissions, read our 4 Lessons Learned from Hybrid Measure Submissions.

 

3. Submit One Chart-Abstracted Measure Quarterly

As a reminder, CMS has eliminated the PC-01 Elective Delivery abstracted measure for 2024. That leaves you with just one chart-abstracted measure for now.

 

	REQUIREMENT: Hospitals must report on one chart-abstracted measure: Sepsis.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Quarterly Submission Deadlines

 

SHORT NAME	MEASURE NAME	DISCHARGE DATES	SUBMISSION DEADLINE
SEP-1 (Sepsis)	Severe Sepsis and Septic Shock	Q1 2024 Q2 2024 Q3 2024 Q4 2024	8/15/2024* 11/15/2024* 2/15/2025* 5/15/2025*

*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.

4. Submit Two Structural Measures Annually

	REQUIREMENT: Hospitals must attest to two structural measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

 

SHORT NAME	MEASURE NAME	DATES	SUBMISSION DEADLINE
Maternal Morbidity	Maternal Morbidity Structural Measure	January 1, 2024 – December 31, 2024	May 15, 2025*
HCHE	Hospital Commitment to Health Equity	January 1, 2024 – December 31, 2024	May 15, 2025*

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

As established in the 2023 IQR program requirements, CMS has created a new designation 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.

5. Submit Two Process Measures Annually

The two Social Drivers of Health (SDOH) measures that were voluntary in 2023 are now mandatory in 2024.

	REQUIREMENT: Hospitals must report on two process measures
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: May 15, 2025

 

SHORT NAME	MEASURE NAME	DATES	SUBMISSION DEADLINE
SDOH-1	Screening for Social Drivers of Health	January 1, 2024 – December 31, 2024	May 15, 2025*
SDOH-2	Screen Positive Rate for Social Drivers of Health	January 1, 2024 – December 31, 2024	May 15, 2025*

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

Data Collection Considerations

Hospitals may use a self-selected screening tool to implement these measures. CMS points to AHC Health-Related Social Needs Screening Tool which outlines the questions you could put on a form for patients to answer. This is recommended, not required.

CMS also acknowledges that this data could come from multiple sources: administrative claims data, electronic clinical data, standardized patient assessments, or patient-reported data and surveys. For more guidance, be sure to read our Intro to CMS’s SDOH Measures guide.

6. Submit Population and Sample Size Data Quarterly

	REQUIREMENT: Hospitals must submit population and sampling numbers for the one required chart-abstracted measure: Sepsis.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Quarterly Submission Deadlines

*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 the chart-abstracted sepsis measure. This requirement only applies to populations for chart-abstracted measures. It must be completed quarterly through the Hospital Quality Reporting (HQR) System.

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.

7. Report HCAHPS Data Quarterly

CMS did not make any changes to the 2024 HCAHPS measure requirements.

	REQUIREMENT: Hospitals must report Patient Experience of Care Survey measures data.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	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.

8. On An Annual Basis, Complete the DACA

CMS did not make any changes to the 2024 DACA requirements.

	REQUIREMENT: Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	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, 2025. Hospitals may complete the DACA within the Hospital Quality Reporting (HQR) System.

9. 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.

10. Review Your Claims-Based Data

Hospitals will receive a score for their performance on 11 Claims-Based measures in four categories: patient safety, mortality/complications, coordination of care, and payment. This is one less measure than last year, now that the Hospital-Wide All-Cause Unplanned Readmission Measure (READM-30-HWR) has been retired.

	REQUIREMENT: Hospitals are evaluated for their performance on 11 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 

Claims-Based Payment Measures 

Extra Credit: Begin Data Collection on the PRO-PM Measure

The new Hospital-Level Total Hip Arthroplasty/Total Knee Arthroplasty Patient-Reported Outcome-Based Performance Measure (THA/TKA PRO-PM) marks the first time that the IQR program will rely directly on patient input to calculate your performance in a specific measure. It’s specifically designed to measure your hospital’s rate of improvement in patients’ self-reported pain and function following elective primary THA/TKA.

Because the post-op data collection window is so large, there is a long lead time between the year an eligible procedure occurs and the year it actually gets included with your submitted data. As such, the data collection periods for the Reporting Year 2023 and 2024 voluntary reporting periods are already underway. Fortunately, you still have plenty of time to start collecting data to meet your voluntary submission requirements.

If you do not plan to participate in the voluntary periods (although we strongly advise that you DO) please note that your pre-op data collection for the mandatory Reporting Year 2025 (which begins July 1, 2024) starts on April 2, 2024. This measure may prove to be somewhat complicated to set up in your hospital, so we recommend reading our Quick Guide to the THA/TKA PRO-PM Measure now to get a head start.

	REQUIREMENT: Hospitals must begin pre-op data collection for the THA/TKA PRO-PM.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Pre-op data submission closes September 30, 2025