2025 Hospital IQR Requirements

If you’re trying to make sense of your 2025 Hospital Inpatient Quality Reporting (IQR) program requirements, it may feel like everything has changed and yet nothing has changed. The biggest adjustment—and it’s a doozy—is that it’s your first year of mandatory PRO-PM reporting. On the other hand, aside from a handful of minor updates, pretty much everything else is steady as she goes. (But don’t get too comfortable; CMS certainly has bigger updates up its sleeve.)

So, while IQR requirements are never easy, let’s enjoy this period of relative calm while we can. This step-by-step guide to your 2025 Hospital IQR requirements can help you make it your most successful reporting year yet.

What is the Hospital IQR Program?

Created in 2003 under the Medicare Prescription Drug, Improvement, and Modernization Act (MMA), the IQR program allows CMS to monitor and incentivize hospitals’ performance in specific quality of care measures. Hospitals receive a penalty (in the form of a decrease to their Medicare claims) based on whether they successfully met all requirements of the program. CMS also publishes hospitals’ results in order to further incentivize them towards performance improvement, and to help consumers make better-informed decisions about their care.

Since its launch, 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 today’s hospitals. 

Is the IQR Program Mandatory?

CMS states that the IQR program is voluntary. But don’t let that fool you. For eligible hospitals that fail to meet the requirements in a given year, CMS will reduce their Medicare payment rates by 25% of the Market Basket Update amount. So, if your hospital intends to remain financially solvent, IQR participation is pretty much mandatory. 

Also see: How does the IQR penalty work?

Now that we know where we stand, let’s move on to the 2025 IQR program requirements.

Summary of Changes to the IQR Requirements

NEW: Mandatory PRO-PMs

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

NEW: Available eCQMs

1. HH-PI: Hospital-Harm—Pressure Injury
2. HH-AKI: Hospital Harm—Acute Kidney Injury
3. IP-ExRad: Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults

NEW: Mandatory Structural Measures

1. Patient Safety: Patient Safety Structural Measure
2. Age Friendly Hospital: Age Friendly Hospital Structural Measure

NEW: Claims Measures

1. FTR: 30-Day Risk-Standardized Death Rate Among Surgical Inpatients with Complications (Failure-to-Rescue) Measure

RETIRED: Claims Measures

1. CMS PSI 04: Death Rate Among Surgical Inpatients with Serious Treatable Complications
2. AMI Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI)
3. HF Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Heart Failure (HF)
4. PN Payment: Hospital-Level, Risk-Standardized Payment Associated with a 30-day Episode-of-Care for Pneumonia
5. THA/TKA Payment: Hospital-Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

2025 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 COVID-19 Immunization, Healthcare-Associated Infection (HAI) measure

These mandatory requirements are due annually:

1. Submit one PRO-PM measure (pre-op data + post-op data)
2. Submit six eCQMs (three required + three self-selected)
3. Voluntarily submit two hybrid measures (NOTE: CMS pulled back this mandatory requirement to be voluntary for one more year. This is the last voluntary reporting year.)
4. Submit four structural measures
5. Submit two process measures
6. Complete the Data Accuracy and Completeness Acknowledgement (DACA)
7. Submit the Influenza Immunization Healthcare-Associated Infection (HAI) measure

You must also:

1. Regularly review your claims-based data 

1. Submit One PRO-PM Annually

We’ll start with the biggest change to your IQR requirements in 2025: mandatory reporting of the Hospital-Level Total Hip Arthroplasty/Total Knee Arthroplasty Patient-Reported Outcome-Based Performance Measure (THA/TKA PRO-PM). This marks the first time that the IQR program will rely directly on patient input to calculate your performance on a specific measure.

	REQUIREMENT: Hospitals must submit pre-op and post-op data for the THA/TKA PRO-PM.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Pre-op data: September 30, 2025  Post-op data: September 30, 2026

Additional THA/TKA PRO-PM requirements

CMS requires pre- and post-op data to be collected using the HOOS, JR. form for THA patients, and the KOOS, JR. form for TKA patients. You can download both forms here.

Your pre-op data collection process will also need to include a handful of “Patient- or Provider-Reported Risk Variable” screenings that, along with the patient’s 12-month administrative claims history, will be used to risk-adjust your hospital’s outcome. For more details on this measure and to access the recommended screening tools, please visit our THA/TKA PRO-PM guide.

CMS will accept your data as a CSV or XML file, or you can opt to manually enter your data into CMS’s Hospital Quality Reporting system, or you can have someone like Medisolv take care of the submissions for you.

Preparing for your 2026 PRO-PM requirements

Keep in mind that pre-op data collection for your 2026 PRO-PM requirements will need to happen concurrently. Eligible procedures for the 2026 reporting year begin on July 1, 2025, with pre-op data collection for those procedures opening on or around April 2, 2025.

2. Submit Six eCQMs Annually

Just like last year, you must submit four quarters (a full year) of data on three mandatory eCQMs and three self-selected ones, and CMS will publicly report your performance on Care Compare. Be prepared for this requirement to steadily ramp up, with CMS proposing a mandatory submission of eight eCQMs in 2026, nine in 2027, and 11 by 2028. CMS is also using 2025 to introduce a new eCQM auditing process that could also impact you in the years ahead (see below).

The good news is that CMS is giving you more and more options to choose from, adding three available eCQMs to the list for 2025.

	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, 2026*

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

New! eCQM Auditing Process

Beginning in 2025, CMS will modify the data validation (audit) scoring system to include two distinct validation scores: one for clinical processes of care (CPoC) measures and one for eCQMs. Each score will carry an equal weight (50%). Hospitals must achieve passing scores in both measure types to secure the full annual payment update.

Previously, eCQM validation was assigned a weight of zero to allow hospitals time to gain experience with eCQM reporting and validation. However, hospitals that undergo audits from now on will have their eCQMs assessed for data accuracy, with a minimum acceptable accuracy threshold set at 75%.

Additional eCQM requirements

Your vendor/EHR must be certified to the latest Certified EHR Technology (CEHRT) version for reporting in 2025. Your vendor/EHR must also be certified to for all available eCQMs regardless of which eCQMs you submit.

All data must be submitted using the QRDA (Quality Reporting Document Architecture) Category I file format. 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’s file.

Hospitals must use the most recent version of the eCQM specifications.

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.

3. Voluntarily Submit Two Hybrid Measures Annually

CMS did make changes to the 2025 hybrid measure requirements. It is no longer mandatory. CMS has extended the voluntary reporting period by one more year. Therefore, the hybrid measures are technically voluntary for the reporting dates below.

	REQUIREMENT: Hospitals may voluntarily report four quarters of data for the two Hybrid measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: October 1, 2025*

*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.

As of July 1, 2024, both hybrid measures include Medicare Advantage beneficiaries in addition to Fee for Service (FFS) Medicare beneficiaries.

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

4. Submit One Chart-Abstracted Measure Quarterly

CMS did not make any changes to the 2025 chart-abstracted measure requirements.

	REQUIREMENT: Hospitals must report on one Chart-Abstracted measure: Sepsis.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Quarterly Submission Deadline

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

Hospitals with five or fewer discharges

For this measure, hospitals with five or fewer discharges (both Medicare and non-Medicare combined) in a quarter are not required to submit patient-level data.

Sampling information

SEP-1 employs a sampling methodology, and hospitals may choose monthly or quarterly sampling. Sample sizes depend on which period you’ve selected. Hospitals may sample above their sample sizes.

5. Submit Population and Sample Size Data Quarterly

CMS did not make any changes to the 2025 population and sampling requirements for the SEP-1 chart-abstracted measure.

	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 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 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.

6. Submit Four Structural Measures Annually

This year, CMS is doubling the number of structural measures you are required to submit, from two to four. Details for the two new measures are below.

	REQUIREMENT: Hospitals must submit four Structural measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System & National Healthcare Safety Network (NHSN) Portal (Patient Safety Structural Measure only)
	DEADLINE: May 15, 2026*

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

Patient Safety Structural Measure

This measure assesses how well your hospital has implemented strategies and practices to strengthen its systems and culture for safety. You must attest to each of the five domains and corresponding elements:

1. Domain 1: Leadership Commitment to Eliminating Preventable Harm
2. Domain 2: Strategic Planning & Organizational Policy
3. Domain 3: Culture of Safety & Learning Health Systems
4. Domain 4: Accountability & Transparency
5. Domain 5: Patient & Family Engagement

Each domain is worth one point, allowing for a total score ranging from 0 to 5. Results will be publicly posted in the fall of 2026.

This measure is submitted through the NHSN portal unlike all the other Structural measures.

Age-Friendly Hospital Measure

This measure assesses your hospital’s commitment to improving care for patients 65 years or older receiving services in your hospital, operating room, or emergency department.

You must attest to each of the five domains and corresponding elements:

1. Domain 1: Eliciting Patient Healthcare Goals
2. Domain 2: Responsible Medication Management
3. Domain 3: Frailty Screening and Intervention
4. Domain 4: Social Vulnerability
5. Domain 5: Age-Friendly Care Leadership

Like the Patient Safety measure, each domain is worth one point, for a total score range of 0 to 5.

7. Submit Two Process Measures Annually

CMS did not make any changes to the 2025 process measure requirements.

	REQUIREMENT: Hospitals must submit two Process measures annually.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: May 15, 2026*

*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 the 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.

8. Report HCAHPS Data Quarterly

In 2025, CMS is modifying the HCAHPS Survey by removing some measures (questions) and adding new ones. This will bring the total number of measures (questions) from 29 to 32. You can download HCAHPS's crosswalk of the survey changes here.

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

*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.

9. Complete DACA Annually

CMS did not make any changes to the 2025 DACA requirements.

	REQUIREMENT: Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: May 15, 2026

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 submit to the program is accurate and complete to the best of their knowledge. You can attest anytime between April 1 - May 15, 2026. Hospitals may complete the DACA within the Hospital Quality Reporting (HQR) System.

10. 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)  COVID-19 Vaccination (Quarterly Submission)

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

On a Related Note: New Conditions of Participation (CoPs) Requirements

Starting November 1, 2024, hospitals and CAHs must electronically report certain data elements about COVID-19, influenza, and respiratory syncytial virus (RSV) on a weekly basis. The information includes confirmed infections of respiratory illnesses, including COVID-19, influenza, and RSV, among hospitalized patients, hospital bed census, and capacity. Additionally, you must submit limited patient demographic information, including age.

11. Review Your Claims Data

CMS is simplifying its Claims measures for 2025, reducing last year’s five payment measures down to just one: Medicare Spending per Beneficiary (MSPB).

It’s also replacing last year’s sole patient safety measure (PSI-04) with a new one: the 30-Day Risk-Standardized Death Rate Among Surgical Inpatients with Complications (Failure-to-Rescue) Measure. This brings the total claims measures on which you’ll be scored down from 11 in 2024 to just seven in 2025.

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

Claims-Based Patient Safety Measures 

Claims-Based Mortality/Complication Measures 

Claims-Based Coordination of Care Measures 

Claims-Based Payment Measures 

Extra Credit: Prepare for TEAM

As you may already know, CMS is getting ready to launch a brand-new bundled payment model called the Transforming Episode Accountability Model (TEAM).

TEAM is mandatory for acute care hospitals that bill for five pre-selected episodes of care (see chart below); are paid under the IPPS; have a CMS Certification Number (CCN); and have a primary address located in one of the ~200 geographic areas selected for participation in TEAM. Download: TEAM Eligible Geographic Areas List >>

What Episodes of Care Does TEAM Track?

1. Coronary Artery Bypass Graft (CABG)
2. Lower Extremity Joint Replacement (LEJR)
3. Major Bowel Procedure
4. Surgical Hip/Femur Fracture Treatment (SHFFT)
5. Spinal Fusion

For hospitals that meet the above criteria, mandatory participation will begin January 1, 2026, and run through December 31, 2030. Hospitals may also elect to voluntarily participate if they aren’t included in the geographic selection list.

While TEAM does not require you to make any additional submissions, your current and future performance in select Quality measures related to the model’s five episodes of care will determine your payment or penalty in the year(s) ahead. Here’s a snapshot of year one (2026):

We recommend that you begin preparing your team for these major changes now. Need a place to start? Read and share our article What is TEAM? An overview of the CMS TEAM Model.

2025 IQR Next Steps

Even in a year when there are fewer surprises, Hospital IQR requirements can still be incredibly overwhelming. That’s where Medisolv can lend a hand. Our game-changing Hospital Quality Reporting package makes it dramatically easier to meet all your IQR requirements (even PRO-PMs!), ensure your full Medicare reimbursements, and—most importantly—advance patient care every day.

Yes, I’d Like More Help Please!

• Talk: Schedule a 1:1 Call
• Watch: THA/TKA PRO-PM FAQs Webinar 
• Subscribe: Visit Our Education Center
• Read: The Medisolv Guide to the 2025 IPPS Final Rule