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

Forms and Documents

Document Name	Status
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Unchanged
CMS-10210 HIQR FY 2025 FR Supporting Statement B_clean.docx Supporting Statement B	2024-09-13
CMS-10210 HIQR FY 2025 FR Supporting Statement A_clean.docx Supporting Statement A	2024-09-13

IC Document Collections

IC ID	Document Title	Status
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 202409-0938-008
Status: Received in OIRA	Previous ICR Reference No: 202406-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Hospital Reporting Initiative--Hospital Quality Measures (CMS-10210)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/16/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2026
Responses	18,000	18,000
Time Burden (Hours)	2,283,878	2,286,977
Cost Burden (Dollars)	0	0

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Abstract: This request covers data collection requirements for the FY 2027 payment determination and subsequent years. This revised information collection request includes burden for the proposed adoption of the Age Friendly Hospital measure, the proposed increase in the number of eCQMs hospitals would be required to report, and the removal of the Measure Exception Form for NHSN HAI Measures from this information collection in addition to updated data and wage rates impacting previously approved burden calculations.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3001 Name of Law: Affordable Care Act
   PL: Pub.L. 108 - 173 5001(b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   PL: Pub.L. 109 - 171 5001(a) Name of Law: Hospital Quality Improvement
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV34	Final or interim final rulemaking	89 FR 68986	08/28/2024

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Quality Measures and Procedures for Hospital Reporting of Quality Data	CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210	Data Accuracy and Completeness Form ,   Hospital VPB Review and Corrections Form ,   Extraordinary Circumstances Form ,   Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting ,   IQR Notice of Participation Form ,   IQR Reconsideration Request Form ,   Validation Review for Reconsideration Request ,   VBP Appeal Request Form ,   HVBP CMS Independent Review Form ,   Validation Educational Review Form ,   Maternal Morbidity Structural Measure ,   Population and Sampling ,   Hospital Inpatient Quality Reporting Program Denominator Declaration ,   THA/TKA Patient-Reported Outcome-based Performance Measure ,   Social Drivers of Health Structural Measures ,   Hospital Commitment to Health Equity

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	18,000	18,000	0	0	0	0
Annual Time Burden (Hours)	2,283,878	2,286,977	0	-3,099	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: For the CY 2025 reporting period/FY 2027 payment determination, based on the policies in the FY 2025 IPPS/LTCH PPS final rule, we estimate a total burden of 2,283,878 hours and $92,132,545 (a decrease of 22,045 hours and $1,612,451 from our estimate in the FY 2024 IPPS/LTCH PPS final rule). This burden estimate also represents a decrease of 3,099 hours and an increase of $11,856,849 from the currently approved burden estimate of 2,286,977 hours and $80,275,696 for the CY 2023 reporting period/FY 2025 payment determination.

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Annual Cost to Federal Government: $10,571,400

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/16/2024

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