CMS-10210 Hospital Compare Request Form for Withholding/Footnoting

Request Form for Withholding/Footnoting Data for Public Reporting
Overview
Hospitals and other facilities participating in the Hospital Inpatient Quality Reporting (IQR) Program,
Hospital Outpatient Quality Reporting (OQR) Program, PPS-Exempt Cancer Hospital Quality Reporting
(PCHQR) Program, Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program, Ambulatory
Surgical Center Quality Reporting (ASCQR) Program, Hospital Value-Based Purchasing (VBP) Program,
Hospital Readmissions Reduction Program (HRRP), and/or Hospital-Acquired Condition (HAC) Reduction
Program, respectively, agree to have data publicly reported on a designated CMS website. Hospitals
voluntarily reporting inpatient data with an Optional Public Reporting Notice of Participation have the
option to withhold data from public reporting for those measures listed in Table 1.
Hospitals and other facilities participating in the Hospital IQR Program, Hospital OQR Program, PCHQR
Program, IPFQR Program, ASCQR Program, Hospital VBP Program, HRRP, and/or HAC Reduction
Program can submit a request for CMS review to add a footnote to claims-based measure data included in
public reporting on Care Compare or its successor website, for those measures listed in Table 2.

Request Form Submission Information
Please complete the applicable sections of this form and fax or email the completed form to the Inpatient
Value, Incentives, and Quality Reporting Outreach and Education Support Contractor via:
Secure fax:
1-877-789-4443
Email:
QRFormsSubmission@hsag.com

Contact Information
All hospitals and facilities must provide the required contact information; required fields are marked with
an asterisk (*).

Facility/Hospital Specifics
*Facility Name:
*CMS Certification Number
(CCN)/National Provider
Identifier (NPI):
*Street Address:
*City, State, ZIP Code:
*Facility Contact Name:
*Facility Contact Phone Number:

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Request Form for Withholding/Footnoting Data for Public Reporting
Facility/Hospital Chief Executive Officer (or designee)
*Name:

(blank)

*Title:

(blank)

*Date:

(blank)

*Signature:

Withholding/Footnoting Form
This section of the form provides the instructions for completing the withholding/footnoting form and is
divided into subsections for those hospitals voluntarily participating in inpatient public reporting on Care
Compare and those hospitals and facilities that are statutorily included in the Hospital IQR, Hospital OQR,
PCHQR, IPFQR, ASCQR, Hospital VBP, HRRP, and/or HAC Reduction Programs.

Hospitals Voluntarily Participating in Inpatient Public Reporting
The following information is applicable only to those hospitals voluntarily participating in inpatient public
reporting on Care Compare or its successor website, with an Optional Public Reporting Notice of
Participation.
This form must be received no later than the last day of the applicable preview period, for hospitals not
participating in public reporting with an Optional Public Reporting Notice of Participation.
NOTE: Forms received after the end of the preview period will not be considered for that Public Reporting
release.
My hospital has reviewed its Preview Report. For this preview period, we wish to withhold from
public reporting data submitted for the measure(s) as indicated below.
Hospitals voluntarily participating in inpatient public reporting with an Optional Public Reporting Notice of
Participation may withhold any or all of the measures listed in the following table, by marking the Withhold
column. If a measure that is included in the calculation of the Overall Star Rating is withheld from public
reporting, then the Overall Star Rating will be withheld as well.
Table 1: Measures for Withholding for Hospitals Voluntarily Participating in Public Reporting
Measure ID
IMM-3 (HCP Flu Vac)
IMM-4 (HCP COVID-19 Vac)
MORT-30-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
READM-30-AMI
READM-30-CABG
READM-30-COPD
READM-30-HF
READM-30-PN
READM-30-HIP-KNEE
COMP-HIP-KNEE

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Withhold

Measure ID

PSI-10
PSI-11
PSI-12
PSI-13
PSI-14
PSI-15
CMS PSI-90
SEP-1
HCAHPS
Overall Star Ratings
HAI-1 (CLABSI)
HAI-2 (CAUTI)
HAI-3 (SSI: Colon)
HAI-4 (SSI: Hysterectomy)
HAI-5 (MRSA)

Withhold

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Request Form for Withholding/Footnoting Data for Public Reporting
Measure ID
EDAC-30-AMI
EDAC-30-HF
EDAC-30-PN
PAYM-30-AMI
PAYM-30-HF
PAYM-30-PN
PAYM-90-HIP-KNEE
PSI-03
PSI-04
PSI-06
PSI-08
PSI-09

Withhold

Measure ID
HAI-6 (C. diff.)
MSPB-1
Maternal Morbidity
HCHE/FCHE
SDOH-1
SDOH-2
HYBRID HWM
HYBRID HWR

Withhold

Facilities Participating in Hospital IQR, OQR, PCHQR, IPFQR, ASCQR, HVBP,
HRRP, DRA HAC and/or HAC Reduction Programs
The following form is intended to allow facilities that are statutorily required to participate in programs to
request a footnote be added to their data on the Care Compare or its successor website in the event that the
facility identifies errors in their claims-based measure data during the preview or review and correction
period. The footnote would be added to the data and would indicate that the facility has identified errors in
their data. NOTE: Forms received after the end of the applicable program-specific Preview Period or
Review and Corrections Period will not be considered.
My facility has reviewed its Preview Report and/or Review and Corrections Report. We wish to
request CMS review to add a footnote to public reporting data calculated for the program(s) and
measure(s) as indicated below.
Facilities may request CMS review to footnote any or all of the claims-based measures listed in the following
table, by marking the Footnote column for the requested measure(s). When a measure is included in the
calculation of the Overall Star Rating is footnoted, then the Overall Star Rating will be footnoted as well.
Table 2: Measures for Footnoting 1
Measure ID
MORT-30-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
READM-30-AMI
READM-30-CABG
READM-30-COPD
READM-30-HF
HYBRID HWR
READM-30-PN
READM-30-HIP-KNEE
COMP-HIP-KNEE
EDAC-30-AMI
EDAC-30-HF

1

Footnote

Measure ID
PSI-15
CMS PSI-90
MSPB-1
OP-8
OP-10
OP-13
OP-32
OP-35 ADM
OP-35 ED
OP-36
OP-39
FAPH-7
FAPH-30
READM-30-IPF
MEDCONT
PCH-30

Footnote

Footnoting does not affect a facility’s payment adjustment.

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Request Form for Withholding/Footnoting Data for Public Reporting
Measure ID
EDAC-30-PN
PAYM-30-AMI
PAYM-30-HF
PAYM-30-PN
PAYM-90-HIP-KNEE
PSI-03
PSI-04
PSI-06
PSI-08
PSI-09
PSI-10
PSI-11
PSI-12
PSI-13
PSI-14
HYBRID HWM

Footnote

Measure ID
PCH-31
PCH-32
PCH-33
PCH-34
PCH-35
PCH-36
PCH-37
ASC-12
ASC-17
ASC-19
ASC-18
Foreign Object Retained After Surgery
Blood Incompatibility
Air Embolism
Falls and Trauma

Footnote

Justification
In order to review your request for footnoting of claims-based measures, you will need to submit the
following information in box below:
•
•
•

Provide the number of claims that are impacted, including the encounter dates.
Provide a description of the problem.
Provide the plan to fix the claims in error.
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 0938-1022 (Expires XX-XX-XXXX). 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.

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