CMS recently published the FY 2021 final rule for the Inpatient Prospective Payment Systems (IPPS) and has finalized 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 finalized changes to the reporting of eCQMs. Beginning with CY 2021 reporting, CMS finalized 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 are required to report two self-selected quarters of data for CY 2021 reporting period, three self-selected quarters of data for CY 2022 reporting period, and four quarters of data for CY 2023 reporting period and subsequent years.
CMS finalized the addition of a fifth key element used to identify a QRDA I file. In addition to the existing four key elements used to identify a QRDA I file—CMS Certification Number (CCN), CMS Program Name, EHR Patient ID, and Reporting period—CMS finalized adding 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 fifth element will prevent the risk of a file submitted by one vendor being overwritten by another.
Furthermore, CMS finalized publicly displaying eCQM data on 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. CMS plans to publicly display eCQM data on the Hospital Compare website (or its successor website) sometime after that.
Lastly, CMS finalized 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 will be selected for validation of both eCQMs and chart-abstracted measures and be expected to submit data for both. CMS aligned the quarters of submission data used for both chart-abstracted measures and eCQM validation to reduce burden for those hospitals selected for validation. CMS also reduced the number of hospitals selected for validation from up to 800 to up to 400 hospitals, in which up to 200 would be selected randomly and up to 200 would be selected using targeted criteria. Since eCQMs are not currently validated for accuracy, CMS finalized that the eCQM portion of the validation be weighted at zero percent and chart-abstracted measure portion would be weighted at 100 percent starting with the validation of CY 2021 data. Since eCQMs are not scored for accuracy, hospitals are required to submit at least 75 percent of the requested medical records for eCQM validation. CMS will no longer allow 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 is requiring 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 finalized an EHR reporting period of a minimum of any continuous 90-day period in CY 2022. CMS will continue the Query of PDMP measure as an optional measure worth five bonus points in CY 2021. Further, CMS finalized the renaming of 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 new name more accurately reflects the actions required in the measure’s numerator. The former 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 adopted the same eCQM reporting periods as those finalized for IQR. Beginning with CY 2021 reporting, CMS finalized 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 will be required to report two self-selected quarters of data for CY 2021 reporting period, three self-selected quarters of data for CY 2022 reporting period, and four quarters of data for CY 2023 reporting period and subsequent years.
In alignment with the public reporting of eCQM data for IQR, CMS finalized 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.