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2024 Hospital OQR Program Requirements

This year marks a significant evolution in the Outpatient Quality Reporting (OQR) program with the introduction of a new mandatory eCQM and more coming down the line.

As always, we are here to help with a step-by-step guide to everything you need to do to ensure a successful 2024 OQR reporting year. This article explores what's new and what's changed and how your hospital can not only comply with the new requirements but also excel in delivering high-quality patient care.

Take a minute to read through it, then contact us if you have any questions.

Why This Year’s OQR Program is Different

Following CMS’s rollout of the Hospital Inpatient Quality Reporting (IQR) program in 2003, the OQR program was initiated as a mandate of the Tax Relief and Healthcare Act of 2006, and officially launched under the 2009 Outpatient Prospective Payment System (OPPS) Final Rule. Since then, the program has been updated, but in fairly predictable, chart-abstracted measure kind-of ways.

This year is the start of an important evolution: it’s the first year that CMS is introducing a mandatory electronic clinical quality measure (eCQM) into your OQR requirements (the STEMI eCQM). CMS also has official plans to introduce a second eCQM and even a mandatory patient-reported outcome-based performance measure (PRO-PM) over the next few years. We wouldn’t be surprised to see even more big changes emerge in future rulings.

OQR Rewards & Penalties

One thing that hasn’t changed: what’s at stake. Hospitals receive a 2-percentage point payment reduction if they choose not to participate in the OQR program or fail to meet the program’s requirements. Participation is voluntary, however, for critical access hospitals and (obviously) hospitals that do not participate in the OPPS.

CMS also publishes hospitals’ measure results on Care Compare as a means of helping consumers choose which hospitals to go to for their care. So, it’s not just money that’s on the line—it’s your brand image and reputation.

Summary of Changes to the OQR Requirements

NEW Mandatory Measures

  • OP-40: ST-Segment Elevation Myocardial Infarction (STEMI) eCQM
  • OP-37: Outpatient and Ambulatory Surgery Consumer Assessment (OAS CAHPS)

MODIFIED Mandatory Measures

  • OP-29: Colonoscopy Follow-Up Interval
  • OP-38: COVID-19 Vaccination Coverage Among Healthcare Personnel

MODIFIED Voluntary Measures

  • OP-31: Cataracts Visual Function

2024 OQR Requirements Summary

These mandatory requirements are due quarterly:

  1. Submit clinical data for two chart-abstracted measures (OP-18, OP-23)
  2. Submit OAS CAHPS survey data (OP-37)
  3. Submit COVID-19 web-based measure (OP-38)

These mandatory requirements are due annually:

  1. Submit two Hospital Quality Reporting (HQR) web-based measures (OP-22, OP-29)
  2. Submit STEMI eCQM (OP-40)

You must also:

  1. Regularly review your claims-based data 

1. Submit Chart-Abstracted Measures Quarterly

2024 Updates: In CMS’s efforts to transition to a new timeframe for data submission and payment determination, last year’s payment determination (CY 2025) only factored in three quarters of data for your chart-abstracted measures. This year, CMS is officially transitioning to the four-quarter submission model.

 

REQUIREMENT:
Hospitals must report four quarters of clinical data for the two mandatory abstraction measures.

 


SUBMISSION METHOD:
CMS website or designated information system (third-party vendor authorization required)

 


DEADLINE:
Quarterly

 

SHORT NAME

MEASURE NAME

ENCOUNTER
DATES

SUBMISSION DEADLINES

OP-18

Median Time from ED Arrival to ED Departure for Discharged ED Patients

Q1 2024

Q2 2024

Q3 2024

Q4 2024

8/1/2024

11/1/2024

2/1/2025

5/1/2025

OP-23

Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Arrival

 

Hospitals with five or fewer quarterly claims

If you have a measure with five or fewer claims (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.

2. Report CAHPS Data Quarterly

2024 Updates: While it was voluntary last year, the Outpatient and Ambulatory Surgery Consumer Assessment (OAS CAHPS) measure is mandatory this reporting year.

 

REQUIREMENT:
Hospitals must report five facets of the OAS CAHPS survey measure: About Facilities and Staff, Communication About Procedure, Preparation for Discharge and Recovery, Overall Rating of Facility, and Recommendation of Facility

 


SUBMISSION METHOD:
CMS website or designated information system (third-party vendor authorization required)

 


DEADLINE:

Quarterly submission deadlines

 

SHORT NAME

MEASURE NAME

ENCOUNTER DATES

SUBMISSION DEADLINE

OP-37

Outpatient and Ambulatory Surgery Consumer Assessment (OAS CAHPS)

Q1 2024

7/10/2024

Q2 2024

10/9/2024

Q3 2024

1/8/2025

Q4 2024

4/9/2025

 

3. Report COVID-19 Measure Quarterly

2024 Updates: As reflected in the CY 2023 OPPS Final Rule, the COVID-19 vaccination measure’s vaccination definition has been modified to replace the term “complete vaccination course” with the term “up to date.” The numerator has also been updated to specify the “up to date” timeframe based on the CDC’s latest guidelines.

 

REQUIREMENT:
Hospitals submit the COVID-19 web-based measure

 


SUBMISSION METHOD:
National Healthcare Safety Network (NHSN) Portal

 


DEADLINE:
Quarterly Submission Deadline 

 

SHORT NAME

MEASURE NAME

ENCOUNTER DATES

SUBMISSION DEADLINE

OP-38

COVID-19 Vaccination Coverage Among Health Care Personnel

Q1 2024

8/15/2024

Q2 2024

11/15/2024

Q3 2024

2/17/2025

Q4 2024

5/15/2025

 

4. Submit HQR Web-Based Measures Annually

2024 Updates: There are three important updates to note here. The first is for the Colonoscopy measure (OP-29). CMS has revised the measure’s denominator language from “all patients aged 50 years to 75 years” to “all patients aged 45 years to 75 years” to reflect the latest clinical guidelines around when to start screening. There are no changes to the measure numerator, exclusions, or other specifications.

The second update is to the voluntary Cataracts measure (OP-31). In an effort to standardize the measure’s results nationwide, hospitals must now use one of three pre-approved survey instruments in order to assess patients’ pre- and post-surgery visual function:

  • National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25)
  • Visual Functioning Patient Questionnaire (VF-14)
  • Visual Functioning Index Patient Questionnaire (VF-8R)

Lastly, if you were hoping that CMS would follow through on its proposal to retire the Left Without Being Seen measure (OP-22) this year, we’re sorry to disappoint. Per the final rule, they “have received new data indicating an increase/worsening in Left Without Being Seen rates that [they] believe warrants further investigation” before sunsetting the measure. So, you must report it again this year.

 

REQUIREMENT:
Hospitals submit the Left Without Being Seen (OP-22) and Colonoscopy Follow-Up (OP-29) measures. The third measure, Cataracts Visual Function (OP-31) is voluntary.

 


SUBMISSION METHOD:
CMS website or designated information system (third-party vendor authorization required)

 


DEADLINE:
May 15, 2025 

 

SHORT NAME

MEASURE NAME

ENCOUNTER DATES

SUBMISSION DEADLINE

OP-22

Left Without Being Seen

1/1/24-12/31/24

5/15/25

OP-29

Colonoscopy Follow-Up Interval

OP-31

Voluntary: Cataracts Visual Function

 

5. Report STEMI eCQM Annually

2024 Updates: The STEMI eCQM, which was voluntary last year, is now mandatory this year. While this year only requires you to submit one quarter of data, you will be required to submit one additional quarter each subsequent year, culminating in all four quarters of data being required in 2027. Be sure to read our guide to setting up this measure if you haven’t already!

 

REQUIREMENT:
Hospitals submit one self-selected quarter of data for the STEMI eCQM

 


SUBMISSION METHOD:
CMS website or designated information system (third-party vendor authorization required)

 


DEADLINE:
May 15, 2025 

 

SHORT NAME

MEASURE NAME

ENCOUNTER DATES

SUBMISSION DEADLINE

OP-40

ST-Segment Elevation Myocardial Infarction (STEMI) eCQM

1/1/2024 – 12/31/2024

5/15/25

 

Additional eCQM Requirements: Hospitals must use the most recent version of the eCQM specifications. All data must be submitted using the QRDA I (Quality Reporting Document Architecture) file format. File submission must include one QRDA file per patient that contains all episodes of care and the relevant measure data.

If a hospital has five or fewer outpatient STEMI discharges per quarter or 20 or fewer outpatient STEMI discharges per year (Medicare and non-Medicare combined), as defined by the eCQM’s denominator population, it could be exempt from reporting on this eCQM. Case threshold exemptions should be entered on the Denominator Declaration screen within the HQR System during the submission period.

6. Review Your Claims-Based Data

 

REQUIREMENT:
Hospitals are evaluated for their performance on 7 claims-based measures in 2 measure sets: imaging efficiency measures and outcome measures.

 


SUBMISSION METHOD:
No additional submission is required

 


DEADLINE:
No submission deadline 

 

Claims-Based Imaging Efficiency Measures

SHORT NAME

MEASURE NAME

 ENCOUNTER DATES

OP-8

MRI Lumbar Spine for Low Back Pain

7/1/2023 – 6/30/2024

OP-10

Abdomen CT – Use of Contrast Material

OP-13

Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac, Low-Risk Surgery

OP-39

Breast Cancer Screening Recall Rates

 

Claims-Based Outcome Measures

SHORT NAME

MEASURE NAME

 ENCOUNTER DATES

OP-32

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

1/1/2024 – 12/31/2024

OP-35

Admissions and Emergency Department (ED) Visits for Patients Receiving Outpatient Chemotherapy

OP-36

Hospital Visits After Hospital Outpatient Surgery

 

7. Submit Population and Sample Size Data Quarterly

 

REQUIREMENT:
Hospitals must submit population and sampling numbers for the two chart-abstracted measures and the Colonoscopy HQR web-based measure.

Hospitals must also submit numbers for the voluntary Cataracts HQR web-based measure if participating in the measure.

 


SUBMISSION METHOD:
CMS website or designated information system (third-party vendor authorization required)

 


DEADLINE:

Quarterly Submission Deadlines

 

SHORT NAME

MEASURE NAME

ENCOUNTER
DATES

SUBMISSION DEADLINES

OP-18

Median Time from ED Arrival to ED Departure for Discharged ED Patients

Q1 2024

Q2 2024

Q3 2024

Q4 2024

8/1/2024

11/1/2024

2/1/2025

5/1/2025

OP-23

Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation Within 45 Minutes of Arrival

OP-29

Colonoscopy Follow-Up Interval

OP-31

Cataracts Visual Function (if submitting the voluntary measure)

 

Note: Hospitals are not required to sample their data if they elect to include all eligible cases. For example, a hospital has 100 cases for the quarter and must select a sample of 80 cases. The hospital may choose to use all 100 cases given the minimal benefit sampling would offer. Each measure has its own sampling requirements that must be met. CMS has outlined the latest requirements here.

8. Plan Ahead for the 2025 OQR Reporting Year

As we mentioned at the top, this year is the start of a major evolution in the OQR program. Per the final rule, CMS has promised two new measures in the next three years:

  • NEW: ExRad eCQM – Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital-Level, Outpatient) Electronic Clinical Quality Measure
  • NEW: THA/TKA PRO-PM - Risk Standardized Patient-Reported Outcome-Based Performance Measure (PRO-PM) Following Elective Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the HOPD Setting

We recommend using this year to strategize how your hospital will address each of these measures, so that you can take full advantage of the voluntary reporting periods when they start. The more voluntary reporting you do, the better your mandatory reporting rates will be. 

MEASURE

VOLUNTARY

MANDATORY

IMPORTANT NOTE

ExRad eCQM

2025
2026

2027
(2029 payment determination)

Read our how-to guide for setting up the measure to get a head start.

 

THA-TKA PRO-PM

2025
2026
2027

2028
(2031 payment determination)

CMS has indicated that it intends to use the same specifications as the IQR version of this measure. You can brush up on the IQR version of the measure here.

Additionally, this measure is unique to the OQR program in that there will be a three-year span between reporting year and payment determination year (instead of the usual two). This is intended to give you sufficient time for post-op survey gathering.

 

Get 1:1 Help With Your OQR Requirements

If you’re still feeling overwhelmed by your OQR requirements, Medisolv is just one call away. We work with leading hospitals and health systems across the country just like yours to organize, update, simplify, and streamline their OQR program reporting and processes. Plus, our Medisolv Quality Reporting and Management software platform makes it dramatically easier to meet all your regulatory requirements, maximize your reimbursements, and improve patient care every day.

Yes, I’d Like More Help Please!

 

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 Clinical Quality Advisor 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-on-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 Clinical Quality Advisor that you can call anytime with questions or concerns. 

Contact us today.

 

 

Erin Heilman

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

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