Summary of Updates on HIQR Collection Forms

Summary of HQR Information Collection Forms - FY2025 IPPS Final Rule - HQR PRA Package.docx

Hospital Reporting Initiative--Hospital Quality Measures (CMS-10210)

Summary of Updates on HIQR Collection Forms

OMB: 0938-1022

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FY 2025 Inpatient Prospective Payment System Rule: Summary of Updates on Hospital Quality Reporting Information Collection Forms


Form

Notes on Updates

  1. Hospital Inpatient Quality Reporting Notice of Participation

  • No updates made.

  1. Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)

  • Updated and consolidated the requirements that are included under the DACA.

  1. Care Compare Request Form for Withholding/Footnoting Data for Public Reporting

  • Table 1: Minor change for consistency with HAI measures and added measures.

  • Table 2: Reordered the table to group program measures and added new ones.

  1. CMS Quality Reporting Program APU Reconsideration Request Form

  • Updated validation section.

  1. CMS Hospital IQR Program Validation Review for Reconsideration Request Form

  • Updated guidance related to submitting validation reconsideration medical records.

  1. Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form

  • Added new Rural Emergency Hospital Quality Reporting Program to form.

  • Updates to language for clarity, alignment, and inclusion of CY 2025 measures/requirements.

  1. Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form

  • Changed the time frame for which the form is due from 30 days from the ListServ announcement to 30 days from when the report is available.

  1. Hospital Value-Based Purchasing (VBP) Program Appeal Request Form

  • No updates made.

  1. Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form

  • No updates made.

  1. Maternal Morbidity Structural Measure

  • Removed the paragraph regarding not being able to use the PC-01 IPPS Measure Exception1 form as hospitals will know this by CY 2025 since the measure was removed beginning CY 2024.

  1. Population and Sampling

  • No updates made.

  1. CMS Quality Reporting Validation Educational Review Form

  • No updates made.

  1. Electronic Clinical Quality Measure (eCQM) Denominator Declaration

  • Screenshot of the data form in the Hospital Quality Reporting (HQR) system. The verbiage about the measures table was updated to reflect what is in HQR.

  1. Total Hip Arthroplasty/Total Knee Arthroplasty (THA-TKA) Patient-Reported Outcome-based Performance Measure (PRO-PM)

  • This is the initial time that this data form is going through the PRA process.

  • Screenshot of the data form in HQR.

  1. Social Drivers of Health (SDOH) Measure

  • This is the initial time that this data form is going through the PRA process.

  • Screenshot of the data form in HQR.

  1. Hospital Commitment to Health Equity (HCHE) Measure

  • This is the initial time that this data form is going through the PRA process.

  • Screenshot of the data form in HQR.

1 The IPPS Measure Exception Form was removed from the IQR PRA Package and added to the HACRP PRA Package beginning CY 2024 due to the removal of the PC-01 measure from the Hospital IQR Program. This form now includes only the Healthcare-Associated (HAI) measures.

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