CMS and The Joint Commission have made changes to hospital’s quality reporting requirements for 2019 and 2020 in response to the COVID-19 pandemic. We’ve summarized the changes below and created a download for you to have (click the image below). As things change, we will keep this up to date.
At a very high level, for most quality reporting programs they’ve made it optional to submit Q4 2019 data. Additionally, Q1 and Q2 2020 data is not required to be submitted for most quality reporting programs.
Hospital Programs
HAC
Hospital-Acquired Condition Reduction Program
2019
NHSN HAI Measures:
Q4 data submission is optional.
If you do submit HAI measures:
CMS will use your entire year of data including Q4 to calculate your payment.
If you don’t submit HAI measures:
CMS will use the data you submitted for January 1 – September 30 to calculate your performance and payment (where appropriate).
2020
Requirement change:
Data from the Q1 & Q2 time period will not be calculated for performance or penalty.
NHSN HAI Measures:
Q1 & Q2 data submission is optional.
PSI-90 Composite Measure:
Q1 & Q2 discharges excluded.
If you do submit HAI measures:
CMS will use the data you submit to calculate your performance and penalty (where appropriate). You may submit an ECE request form to exclude this data from consideration.
If you don't submit HAI measures:
CMS will only use 2020 Q3 and Q4 data to calculate your performance and penalty (where appropriate).
HRRP
Hospital Readmissions Reduction Program
2019
Requirement change:
No requirement changes.
2020
Requirement change:
Q1 & Q2 discharges excluded from readmission calculations.
HVBP
Hospital Value-Based Purchasing Program
2019
NHSN HAI Measures:
Q4 data submission is optional.
HCAHPS:
Q4 data submission is optional.
If you do submit HCAHPS:
CMS will use your entire year of data including Q4 to calculate your payment.
If you don’t submit HCAHPS:
CMS will use the data you submitted for January 1 – September 30 to calculate your performance and payment (where appropriate).
2020
NHSN HAI Measures:
Q1 & Q2 data submission is optional.
HCAHPS:
Q1 & Q2 data submission is optional.
Claims:
Q1 & Q2 discharges excluded for all claims-based measures.
If you do submit HCAHPS:
CMS will use the data you submit to calculate your performance and payment (where appropriate).
If you do submit HCAHPS:
CMS will only use 2020 Q3 and Q4 data to calculate your performance and payment (where appropriate).
If you ask to be exempted:
If you submit an ECE form you are exempted from the program for the entire year. You won't receive a penalty but you cannot receive an incentive payment either.
IPFQR
Inpatient Psychiatric Facility Quality Reporting Program
2019
Requirement change:
There is no change to 2019 data requirements. You are required to report 2019 discharge data to CMS during the 2020 summer submission period (7/1/2020-8/15/2020).
IMM-2 measure:
Required to report Q4 2019 data.
Note* Medisolv does not submit IPF aggregate data for a hospital.
2020
Requirement change:
Q1 & Q2 data submission is not required and will not be used to determine payments.
IMM-2 measure:
Exclude Q1 2020 data.
If you do submit:
In calculating claims-based measures, CMS will exclude Q1 & Q2 claims. The ECE is optional. Facilities are not required to change any of their current practices if they do not wish to do so.
If you don’t submit:
If a facility elects to modify its data collection in response to the ECE, it does not need to notify CMS.
Note* Medisolv recommends that their clients continue to abstract core measures to maintain internal reporting and trending.
IQR
Hospital Inpatient Quality Reporting Program
2019
Abstracted measures
Q4 data is optional to submit in 2020.
Population & sample size counts
Q4 data is optional to submit in 2020.
eCQMs
No requirement changes. If you were unable to meet the March 2, 2020 deadline you may submit an ECE form by May 1, 2020.
HAI measures
Q4 data is optional to submit in 2020.
HCP Influenza Vaccination (HCP)
You are not required to report this data in 2020.
HCAHPS survey
Q4 data is optional to submit in 2020.
DACA submission
You are not required to submit the 2019 DACA in 2020.
Claims data
No requirement changes.
Audits
• Q3 & Q4 abstracted measure audits do not need to be submitted.
• Q4 HAI audits do not need to be submitted.
• Any 2019 eCQM audit requests do not need to be submitted.
If you do submit:
CMS will use your entire year of data including Q4 to calculate your payment as applicable to each part of the program.
If you don’t submit
CMS will use the data you submitted for January 1 – September 30 to calculate your performance and payment (where appropriate).
Note* Medisolv intends to continue submitting for clients. There will be no disruption to your submissions.
2020
Abstracted measures
Q1 & Q2 data is optional to submit in 2020.
Population & sample size counts
Q1 & Q2 data is optional to submit in 2020.
eCQMs
No requirement changes.
HAI measures
Q1 & Q2 data is optional to submit in 2020.
HCP Influenza Vaccination (HCP)
No changes to 2020 - 2021 reporting period.
HCAHPS survey
Q1 & Q2 data is optional to submit in 2020.
DACA submission
No requirement changes.
Claims data
Q1 & Q2 data will not be considered.
Audits
Q1 & Q2 abstracted measure audits do not need to be submitted.
Note* Medisolv recommends that their clients continue to abstract core measures to maintain internal reporting and trending.
OQR
Hospital Outpatient Quality Reporting Program
2019
Abstracted measures
Q4 data is optional to submit in 2020.
Web-based data
2019 encounters are not required to be submitted.
Claims measures
No requirement changes.
If you do submit:
CMS will use your entire year of data including Q4 to calculate your payment.
If you don’t submit
CMS will use the data you submitted for January 1 – September 30 to calculate your performance and payment (where appropriate).
Note* Medisolv intends to continue submitting for clients. There will be no disruption to your submissions.
2020
Abstracted measures
Q1 & Q2 data is optional to submit.
Web-based data
No requirement changes.
Claims measures
Q1 & Q2 data will not be used.
Note* Medisolv recommends that their clients continue to abstract core measures to maintain internal reporting and trending.
ORYX®
The Joint Commission’s Quality Initiative Program
2019
Requirement change:
Q4 chart-abstracted data submission is optional.
If you do submit:
TJC has extended the deadline for submission from April 30, 2020 to June 1, 2020.
Note* Medisolv intends to continue submitting for clients. There will be no disruption to your submissions.
2020
Requirement change:
Q1 & Q2 chart-abstracted data submission is optional.
If you do submit:
TJC has extended the deadline for submission for Q1 & Q2 as below.
• Q1 2020 deadline extended from July 31, 2020 to Oct. 31, 2020.
• Q2 2020 deadline extended from Oct. 31, 2020 to Jan. 31, 2021.
Note* Medisolv recommends that their clients continue to abstract core measures to maintain internal reporting and trending.
PI
Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals
2019
Requirement change:
Q4 data submission is optional.
If you already submitted:
CMS will use your entire year of data including Q4 to calculate your payment.
If you didn't submit:
The deadline has been extended to submit a hardship request.
Eligible Hospitals deadline is September 1, 2020
Critical Access Hospital's deadline is November 30, 2020.
2020
Requirement change:
Q1 & Q2 data submission is not required and will not be used to determine payments.
Other Programs
- Ambulatory Surgical Center Quality Reporting Program]
- PPS-Exempt Cancer Hospital Quality Reporting Program
2019
Requirement change:
ASCs
All data collection and submission requirements that were due by May 15, 2020 for 2019 encounters are not required to be submitted.
PPS-exempt cancer hospitals
Q4 HCP and CDC infection measures do not need to be submitted.
Q4 HCAHPS survey data does not need to be submitted.
2020
Requirement change:
ASCs
All Q1 & Q2 claims-based measures will not be used.
PPS-exempt cancer hospitals
Q1 HCP and CDC infection measures do not need to be submitted.
Q1 & Q2 HCAHPS survey data does not need to be submitted.
Q1 & Q2 claims-based measures will not be used.
Provider Programs
QPP/MIPS
Quality Payment Program
2019
Deadline extension:
The deadline for submitting 2019 MIPS data is extended to April 30, 2020.
CMS reopened the MIPS extreme and uncontrollable circumstances application. If you submit this application before April 30, 2020 and cite COVID-19 it will override any previous data submission.
Requirement Change:
CMS will not calculate Cost as a part of your 2019 score. If, however, you submit your other data by the extended deadline, CMS will add the weight of your Cost score to your Quality score.
If you don’t submit:
CMS will automatically qualify the Eligible Clinician for the extreme and uncontrollable circumstances policy, which provides them a neutral payment adjustment for the 2021 MIPS payment year.
Note* Medisolv intends to continue submitting for clients. There will be no disruption to your submissions.
2020
Requirement change:
CMS is allowing clinicians to submit a hardship application to reweight any or all categories to 0%.
If you participate in a COVID-19 clinical trial you may use that as a high-weighted measure in the Improvement Activity category of MIPS.
Those are the changes as of now. If you have any questions, please feel free to reach out. We want to support our hospitals in any way that we can during this time of difficulty. We can’t thank you enough for what you do for all of us. Our hearts are with you.
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