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CMS recently published the FY 2022 Inpatient Prospective Payment System (IPPS) Final Rule which includes several proposed changes to the Hospital Inpatient Quality Reporting (IQR) Program and Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals (CAHs). For the full text of the rule, see the Federal Register.
Hospital Inpatient Quality Reporting (IQR) Program
CMS has finalized numerous changes related to the Hospital Inpatient Quality Reporting (IQR) Program including the adoption of five new measures and the removal of three existing measures.
First, CMS finalized a new structural measure, Maternal Morbidity Structural Measure, beginning with a shortened reporting period from October 1, 2021 through December 31, 2021 for CY2021 reporting/FY2023 payment. Following this first year, the reporting period will be the full calendar year (January 1, 2022 through December 31, 2022) impacting FY2024 payment. Once a year, hospitals will attest to a two-part question via a CMS-approved web-based tool on the QualityNet website.
Second, CMS finalized adopting the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure (Hybrid HWM measure), which is reported as a single summary score capturing hospital-level, risk-standardized mortality within 30 days of hospital admission for most conditions or procedures. This measure uses three main sources of data: Medicare Part A claims data, a set of core clinical data elements from a hospital’s EHR, and mortality status from the Medicare Enrollment Database. Hospitals are already collecting nine of the ten core clinical data elements used in the Hybrid HWM measure for reporting on the Hybrid HWR measure (previously finalized in the FY2021 IPPS Rule), with platelets being the only additional data element used specifically for the Hybrid HWM measure. For this measure, CMS finalized a voluntary reporting period from July 1, 2022 through June 30, 2023 (in line with the second voluntary reporting period for the Hybrid HWR measure) and a mandatory reporting period beginning July 1, 2023 through June 30, 2024 affecting the FY 2026 payment determination and subsequent years (also in line with the Hybrid HWR measure). While the voluntary data submission will not be publicly reported, the mandatory data submission will be publicly reported on Care Compare website or its successor website.
Next, CMS finalized the addition of the COVID-19 Vaccination Coverage Among Health Care Personnel (HCP) beginning with a shortened reporting period from October 1, 2021 through December 31, 2021 for CY2021 reporting/FY2023 payment. However, beginning with the CY2022 reporting period/FY2024 payment determination, CMS finalized quarterly reporting deadlines in which hospitals would report at least one self-selected week during each month of the reporting quarter to the NHSN Healthcare Personal Safety Component. CMS will publicly report each quarterly COVID-19 HCP vaccination coverage rate as calculated by the CDC.
Finally, CMS finalized two new eCQMs beginning with the CY2023 reporting period/FY2025 payment determination: Hospital Harm—Severe Hypoglycemia and Hospital Harm—Severe Hyperglycemia. These will be available, but not required eCQMs for IQR reporting.
While CMS proposed to remove five measures, CMS finalized the removal of three. CMS finalized the removal of PC-05 Exclusive Breast Milk Feeding eCQM beginning with the CY2024 reporting period/FY2026 payment determination, since the Maternal Morbidity Structural Measure was adopted. CMS also finalized removing ED-2 Admit Decision Time to ED Departure Time for Admitted Patients and STK-06 Discharged on Statin Medication beginning with the CY2024 reporting period/FY2026 payment determination.
CMS did not finalize the removal of STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter or PSI-04 Death Among Surgical Inpatients with Serious Treatable Complications, a claims-based measure.
Beginning with the CY2023 reporting period/FY2025 payment determination, CMS finalized hospitals would be required to use only certified technology that has been updated to the 2015 Edition Cures Update.
Medicare Promoting Interoperability (PI) Program
CMS finalized several changes to the Medicare Promoting Interoperability (PI) Program related to measures and scoring.
First, for CY2023 reporting in the Medicare PI Program, CMS finalized an EHR reporting period of a minimum of any continuous 90-day period for new and returning participants. However, for CY2024 reporting, CMS finalized an EHR reporting period of a minimum of any continuous 180-day period for new and returning participants. Additionally, for CY2022 and subsequent years, CMS finalized increasing the minimum scoring threshold for PI from 50 to 60 points. In other words, a hospital would need to score at least 60 points to be considered a meaningful EHR user and avoid the negative payment adjustment.
Next, CMS finalized numerous changes related to the PI objective measures beginning with CY2022 reporting. To begin, CMS finalized maintaining the Query of the PDMP measure under the Electronic Prescribing Objective as an optional measure, but worth 10 bonus points, instead of 5.
Secondly, CMS finalized modification to the reporting requirements for the Public Health and Clinical Data Exchange Objective by requiring four of the measures: Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting, and Electronic Reportable Laboratory Result Reporting. To receive 10 points for this objective, a hospital must attest “yes” to all four measures or claim exclusions. If a hospital claims exclusions for all four measures, the points will be redistributed to the Provider to Patient Exchange objective. In addition to making Syndromic Surveillance Reporting required, CMS changed the setting from urgent care to the emergency department for which data is required to be submitted beginning with CY2022 reporting. Thus, the first exclusion for this measure was also modified to remove the reference to urgent care. Given these finalized changes, CMS made the Public Health Registry Reporting and Clinical Data Registry Reporting measures optional, and a hospital can earn five bonus points if they report a “yes” response for either measure beginning with CY2022 reporting. Since these two measures would be optional, CMS removed the associated exclusions.
Further, CMS finalized adding the Health Information Exchange (HIE) Bi-Directional Exchange measure to the HIE Objective. This new measure is an optional alternative to the two existing HIE measures: Support Electronic Referral Loops by Sending Health Information and Support Electronic Referral Loops by Receiving and Reconciling Health Information. Thus, hospitals can report either the two existing measures or the new HIE Bi-directional Exchange measure. This new measure would be reported by attestation where a “yes” response would be worth 40 points. Hospitals would be required to engage in bi-directional exchange of information via an HIE for all unique patients admitted to or discharged from the hospital inpatient or emergency department and all unique patient records stored or maintained in the EHR for these departments during the EHR reporting period.
Finally, for CY2022 reporting, CMS added a new SAFER Guides measure to the Protect Patient Health Information objective. To meet this measure, a hospital must attest to one “yes/no” attestation statement to having conducted an annual self-assessment of all nine SAFER Guides at any point during the calendar year in which the EHR reporting period occurs. While this measure is required in CY2022, it would not be scored and a yes or no answer is acceptable without penalty.
CMS did not finalize their proposal to modify the Provide Patients Electronic Access to Their Health Information measure that would require that patient health information remains available to the patient to access indefinitely and using any application of their choice that is configured to meet the technical specifications of the API in the eligible hospital or CAH’s CEHRT.
As CMS continues to align the IQR and PI programs, CMS finalized the same eCQM additions and removals for PI as previously described for IQR. Likewise, in alignment with the IQR program policy, CMS is also requiring hospitals reporting for PI to use only certified technology updated to the 2015 Edition Cures Update beginning with the CY2023 reporting period.
Digital Quality Measurement
CMS’ goal is to move fully to digital quality measurement in CMS quality reporting and value-based purchasing programs by 2025. Digital quality measures (dQMs) use sources of health information that are captured and can be transmitted electronically via interoperable systems. CMS will consider comments received related to dQMs in future rulemaking.
If you have questions about your hospital reporting of eCQMs, Promoting Interoperability measures, or chart-abstracted measures, please contact us.