CMS recently published the FY 2021 proposed rule for the Inpatient Prospective Payment Systems (IPPS) and has proposed changes to the Hospital Inpatient Quality Reporting (IQR) program and Medicare & Medicaid Promoting Interoperability (PI) program for eligible hospitals and critical access hospitals. For the full text of the rule, see the Federal Register.
Hospital Inpatient Quality Reporting (IQR) Program
For the Hospital Inpatient Quality reporting (IQR) program, CMS has proposed changes to the reporting of eCQMs. Beginning with CY 2021 reporting, CMS proposes gradually increasing the number of quarters of eCQM data reported, from one self-selected quarter of data to four quarters of data over a three-year period. To this end, hospitals would be required to report two quarters of data for the CY 2021 reporting period, three quarters of data for the CY 2022 reporting period, and four quarters of data for the CY 2023 reporting period and subsequent years. CMS has not proposed any changes to the measures already finalized in the FY 2020 IPPS Proposed Rule.
CMS also proposes adding a fifth key element used to identify a QRDA I file. Currently, the four key elements used to identify a QRDA I file are: the CMS Certification Number (CCN), the CMS Program Name, the EHR Patient ID, and the reporting period. The proposed new element is the EHR Submitter ID beginning with CY 2021 reporting. For vendors, the EHR Submitter ID is the Vendor ID and for hospitals it is the hospital’s CCN. This proposed fifth element would prevent the risk of a file submitted by one vendor being overwritten by another.
Furthermore, CMS proposes to begin publicly displaying eCQM data on the Hospital Compare website (or its successor website) and data.medicare.gov, beginning with data reported by hospitals for the CY 2021 reporting period and for subsequent years. The data could be made available to the public as early as the fall of 2022 and hospitals would have the opportunity to review their data before they are made public.
Lastly, CMS proposes combining the validation processes for chart-abstracted measures and eCQMs beginning with validation in CY2022 using data from the CY2021 reporting period. A single hospital would be selected for validation of both eCQMs and chart-abstracted measures and would be expected to submit data for both. CMS proposes to align the quarters of submission data used for both chart-abstracted measures and eCQM validation to make it easier for hospitals selected for validation.
CMS proposes to reduce the number of hospitals selected for validation from a maximum of 800 to a maximum of 400, with no more than 200 being randomly selected and up to another 200 selected using targeted criteria. Since eCQMs are not currently validated for accuracy, CMS proposes that the eCQM portion of the validation be weighted at 0% and the chart-abstracted measure portion be weighted at 100% starting with the validation of CY 2021 data. Since eCQMs would not be scored for accuracy, hospitals would still be required to submit at least 75% of the requested medical records for eCQM validation.
In future rulemaking, CMS expects increasing the weighting of the eCQM validation score to account for accuracy of data submitted. CMS proposes to discontinue allowing hospitals to send paper copies of, or CDs, DVDs, or flash drives containing medical records for validation of chart-abstracted measures beginning with the validation of CY 2021 data. Instead, CMS proposes to require hospitals to submit only electronic files via a CMS-approved secure file transmission process when submitting copies of medical records for validation.
Medicare & Medicaid Promoting Interoperability Programs
For the Medicare Promoting Interoperability (PI) program, CMS proposes an EHR reporting period of a minimum of any continuous 90-day period in CY 2022. CMS proposes to continue the Query of PDMP measure as an optional measure worth five bonus points in CY 2021. Further, CMS proposes to rename the Support Electronic Referral Loops by Receiving and Incorporating Health Information measure to Support Electronic Referral Loops by Receiving and Reconciling Health Information, since the proposed name more accurately reflects the actions required in the measure’s numerator. The current name includes “incorporating” which is not always required to meet the numerator, such as when no update or modification is needed within the patient record based on the electronic clinical information received.
CMS also proposes to adopt the same eCQM reporting periods as those proposed for IQR. Beginning with CY 2021 reporting, CMS has proposed gradually increasing the number of quarters of eCQM data reported, from one self-selected quarter of data to four quarters of data over a three-year period. To this end, hospitals would be required to report two quarters of data for CY 2021 reporting period, three quarters of data for CY 2022 reporting period, and four quarters of data for CY 2023 reporting period and subsequent years. CMS has not proposed any changes to the measures already finalized in the FY 2020 IPPS Proposed Rule.
Considering CMS’ proposal to publicly report eCQM data for IQR, CMS also proposes public reporting of eCQM data for PI beginning with CY2021 reporting period data.
If you have questions about your hospital reporting of eCQMs, Promoting Interoperability measures, or chart-abstracted measures, please contact us.