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May 2021 Hospital Reporting Quality Measures

April 22, 2021

4Q 2020 Clinical, HAI, and PC-01 Data Submission Deadline is May 17, 2021

Hospitals participating in the Centers for Medicare & Medicaid Services (CMS) Inpatient Quality Reporting (IQR) and Hospital Acquired-Condition (HAC) Reduction Programs that the data submission deadline for the following requirements is May 17, 2021, at 11:59 p.m. Pacific Time:

  • Fourth quarter (4Q) 2020 Chart-Abstracted Clinical measures (SEP-1)
  • 4Q 2020 Perinatal Care (PC-01) measure
  • 4Q 2020 Healthcare-Associated Infection (HAI) measures

By May 17, 2021, at 11:59 p.m. Pacific Time, IQR and HAC Reduction eligible hospitals are required to:

Important Note: Hospitals can update and correct their submitted clinical data until the IQR submission deadline. After the deadline, the warehouse will be locked, and no further data can be submitted.

IPPS Measure Exception Form for PC-01 Measure: Hospitals that do not deliver babies can submit an IPPS Measure Exception Form. Otherwise, hospitals that do not deliver babies must enter a zero (0) for each of the data-entry fields for each discharge quarter. Please Note: This form must be renewed annually. For hospitals submitting an IPPS Measure Exception Form for CY 2020, CMS must receive it as soon as possible, but no later than the May 17, 2021 deadline.

  • Submit HAI Data for 4Q 2020 through the National Healthcare Safety Network (NHSN) application.

IPPS Measure Exception Form for HAI Measures: Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI): Hospitals that do not have a qualifying intensive care unit and also have no adult or pediatric medical, surgical, or medical/surgical wards are required to submit an IPPS Measure Exception Form for the CLABSI and CAUTI measures at least annually.

Surgical Site Infection (SSI): Hospitals that performed nine or fewer of any of the specified colon and abdominal hysterectomy procedures combined in the calendar year prior to the reporting year are eligible for the SSI measure exception; qualifying hospitals may submit an IPPS Measure Exception Form for SSI-Colon and SSI-Abdominal Hysterectomy at least annually. If an exception is not requested, SSI data must be reported.

Qualifying hospitals can file an HAI measure exception using the IPPS Measure Exception Form. Please Note: This form must be renewed annually. For hospitals submitting an IPPS Measure Exception Form for CY 2020, CMS must receive it as soon as possible, but no later than the May 17, 2021 deadline.

Timely Data Review: Allow ample time before the deadline to review and, if necessary, correct your data. Data modified in NHSN after the submission deadline are not sent to CMS and will not be used in CMS pay-for-performance programs, including the Hospital Value-Based Purchasing Program and the Hospital-Acquired Condition Reduction Program.

Data Submission Verification: To verify the status of your clinical data submission, you can run your Provider Participation Report (PPR) and other applicable reports. To verify the status of your HAI data submission, you can run your Facility, State and National Report. To verify the status of your PC-01 submission, you can run your PPR or check your Inpatient Web-Based Measures summary screen. Please see the 4Q 2020 Hospital IQR Program Checklist for further information.

Extraordinary circumstances exceptions (ece)

In the event that your hospital is unable to submit data or meet requirements due to an extraordinary circumstance related to the COVID-19 Public Health Emergency, you may request an individual exception.

  • For the submission of the HAI data, for the Hospital-Acquired Condition Reduction Program, the ECE must be submitted by May 17, 2021 due to operational timelines and constraints, including informing the National Healthcare Safety Network of final approved ECEs for 4Q 2020 data. Please note HAI reporting impacts performance-based payment adjustments under the Hospital-Acquired Condition Reduction and Hospital Value-Based Purchasing Programs.
  • For the submission of clinical (Sepsis) and PC-01 data, the ECE must be submitted within 90 calendar days from when you determined that the extraordinary event occurred. The event may occur during the measurement period through the submission or reporting deadline.

Please refer to the HACRP, HVBP, and IQR resources on QualityNet for further information.

Hospital Contact Information: To ensure your hospital receives critical communications about meeting the requirements of the IQR Program (and other CMS quality reporting programs), including submission-deadline reminders and program updates, it is important that we have the complete contact information for the key roles at your hospital. Updates to your contact information can be submitted, if needed, using the Hospital Contact Change Form. This document is available on the Quality Reporting Center website (www.qualityreportingcenter.com > Inpatient > Hospital IQR Program > Resources and Tools > Forms).

For further assistance regarding the information contained in this message, please contact the Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Team at https://cmsqualitysupport.servicenowservices.com/qnet_qa?id=ask_a_question or (844) 472-4477.