CMS-10668 Measure Exception Form for Healthcare-Associated Infecti

Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Programs
Measure Exception Form for Healthcare-Associated Infection (HAI) Data
Submission
NOTE: This Measure Exception Form must be renewed at least annually.

This Measure Exception Form may be used for the following Healthcare-Associated Infection
(HAI) measures: Surgical Site Infection (SSI), Catheter-Associated Urinary Tract Infection
(CAUTI), and Central Line-Associated Bloodstream Infection (CLABSI). This form is used by
the Hospital Value-Based Purchasing (VBP) Program and the Hospital-Acquired Condition
(HAC) Reduction Program.
Fields marked with an asterisk (*) are required.
Specify the applicable quarter(s) for the Measure Exception request(s).

*IPPS Measure Exception Information (select all that apply)
Specified Colon and Abdominal Hysterectomy Surgical Procedures
Only hospitals that performed nine or fewer of any of the specified colon and
abdominal hysterectomy surgical procedures combined in the calendar year prior to
the reporting year are eligible for the SSI Measure Exception.
Colon and Abdominal Hysterectomy Surgical Site Infection (SSI)
Hospital performed a combined total of nine or fewer colon surgeries and abdominal
hysterectomies in the calendar year prior to the reporting year.
Calendar Year prior to reporting year (YYYY)

Number of procedures performed

Exclusion requested for Calendar Year (YYYY)

April 2024

Page 1 of 3

Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Programs Measure
Exception Form for HAI Data Submission

Specified CAUTI and CLABSI Requirements
As of January 1, 2015, acute care hospitals are required to report CLABSI and CAUTI
data from all patient care locations that are mapped as National Healthcare Safety
Network (NHSN) adult and pediatric medical, surgical, and medical/surgical wards – as
provided in the table below – in addition to the ongoing reporting from intensive care
units (ICU).
CDC Location Label
Medical Ward
Medical/Surgical Ward
Surgical Ward
Pediatric Medical Ward
Pediatric Medical/Surgical Ward
Pediatric Surgical Ward

CDC Location Code
IN:ACUTE:WARD:M
IN:ACUTE:WARD:MS
IN:ACUTE:WARD:S
IN:ACUTE:WARD:M_PED
IN:ACUTE:WARD:MS_PED
IN:ACUTE:WARD:S_PED

Hospitals that do not have the applicable locations for the CLABSI and CAUTI
measures must submit an IPPS Measure Exception Form each year to be excepted
from CLABSI and CAUTI reporting for CMS programs. Any unit that does not meet the
definition of an ICU, Neonatal ICU, or one of the six wards listed above (e.g., unit
mapped as orthopedic ward, telemetry ward, step-down unit) will not be required for
CMS IPPS reporting; any data reported from non-required units in NHSN will not be
submitted to CMS.
Catheter-Associated Urinary Tract Infection (CAUTI)
Hospital has no ICU locations and no adult or pediatric medical, surgical, or medical/surgical
wards.
Calendar Year (YYYY)
January 1 through March 31

April 1 through June 30

July 1 through September 30

October 1 through December 31

Central Line-Associated Bloodstream Infection (CLABSI)
Hospital has no ICU locations and no adult or pediatric medical, surgical, or medical/surgical
wards.
Calendar Year (YYYY)
January 1 through March 31

April 1 through June 30

July 1 through September 30

October 1 through December 31

April 2024

Page 2 of 3

Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Programs Measure
Exception Form for HAI Data Submission

*Facility Contact Information
*CMS Certification Number (CCN):
*Facility Name:
*CEO/Designee Last Name:
*CEO/Designee First Name:
*Title:
*CEO/Designee Email Address:
*CEO/Designee Telephone Number_____________________ ext.
I hereby certify that the facility meets the exception criteria and therefore has no data to submit
related to the SSI, CLABSI, and/or CAUTI measures, as indicated on this form.
*Name:
*Position:
*Signature:

Submission Instructions
Complete and submit this form via email to QRFormsSubmission@hsag.com, secure fax
to 877-789-4443, or Hospital Quality Reporting Secure Portal, Managed File Transfer to
QRFormsSubmission@hsag.com.
Following receipt of this request form, CMS will provide an email acknowledgement that the
request has been received.
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1352 (Expires 11-30-2025). The time required to complete this information collection is estimated to average
10 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850. ****CMS Disclosure**** Please do not
send applications, claims, payments, medical records or any documents containing sensitive information to
the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be
reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor at (844) 472-4477.
April 2024

Page 3 of 3