CMS-10210 Hospital Inpatient Quality Reporting Program Denominator

Hospital Inpatient Quality Reporting Program
Denominator Declaration
Please Note: A data collection tool available within the Hospital Quality Reporting system via the Hospital
Quality Reporting Secure Portal allows hospitals to complete and submit their denominator declaration
data. This document is a representation of the text contained in the denominator declaration data form
and is for reference purposes only.

Denominator Declaration

Discharge Quarter

For each measure, determine how many cases from the discharge quarter
meet the Initial Patient Population (IPP) requirements. If you have:
• Five or fewer cases: Select the appropriate number (0-5).
• More than five cases: Leave the dropdown blank. Submit your measure data under eCQM
submissions.
Some measures have different requirements for denominator populations. If none of your cases meet
those requirements, select Zero denominator declaration.
The HQR System will display results of the most recent successful submssion. Resubmitting this form or
submitting via eCQM will overwrite previous submissions.
Measure
Safe Use of
Opioids
PC-02

Zero Denominator Declaration/Case Threshold Exemption
Safe Use of Opioids-Concurrent Prescribing

PC-07

Severe Obstetric Complications

HH-HYPO

Hospital Harm-Severe Hypoglycemia

HH-HYPER

Hospital Harm-Severe Hyperglycemia

STK-2

Discharge on Antithrombotic Therapy

STK-3

Anticoagulation Therapy for Atrial Fibrillation/Flutter

STK-5

Antithrombotic Therapy by End of Hospital Day 2

VTE-1

Venous Thromboembolism-Prophylaxis

VTE-2

Intensive Care Unit Venous Thromboembolism

HH-ORAE

Hospital Harm – Opioid-Related Adverse Events

MCS

Malnutrition Care Score

IP-ExRad

Excessive Radiation Dose or Inadequate Image Quality
for Diagnostic Computed Tomography (CT) in Adults
(Facility IQR)
Hospital Harm – Acute Kidney Injury

HH-AKI

Cesarean Birth

Hospital Inpatient Quality Reporting Program
Denominator Declaration
HH-PI

Hospital Harm – Pressure Injury

HH-FI

Hospital Harm – Falls with Injury

HH-RF

Hospital Harm – Postoperative Respiratory Failure

I’m ready to submit