Technical User's Guide for Hospice Quality Reporting Data Entry and Submission

Technical User’s Guide for

Hospice Quality Reporting
Data Entry and Submission
January 1 – April 1, 2013

This user Guide is considered a draft until OMB approval of
the data submission is received.

Table of Contents
INTRODUCTION.................................................................................................................. 2
ABOUT THIS GUIDE .......................................................................................................... 2
CONVENTIONS USED IN THIS GUIDE .................................................................................. 2
PRINTING ......................................................................................................................... 4
HELP ............................................................................................................................... 4
BACKGROUND ................................................................................................................... 5
WHO, WHAT, WHEN & HOW .............................................................................................. 6
ACCESS THE HOSPICE QUALITY REPORTING DATA ENTRY SITE ............................... 8
REGISTER AND ACTIVATE YOUR ACCOUNT .................................................................10
LOG IN TO THE HOSPICE QUALITY REPORTING DATA ENTRY SITE ...........................13
ENTER QRP MEASURE DATA ..........................................................................................14
HOSPICE PROVIDER INFORMATION ...................................................................................14
THE STRUCTURAL MEASURE............................................................................................18
NQF #0209 PAIN MEASURE ............................................................................................21
ATTESTATION ..................................................................................................................24

INTRODUCTION
About This Guide
This Technical User’s Guide for Hospice Quality Reporting Data Entry provides
information about how to register for and use the online Hospice Quality Reporting
Data Entry website to submit Hospice Quality Reporting Program (HQRP) data. It is
intended for use by hospice personnel responsible for entering and submitting
HQRP data.
NOTE: This technical user’s guide provides hospice providers with instruction
only about data entry site use and data entry specifications.
For instructions regarding data collection and reporting requirements, please
refer to the User Guide for Hospice Quality Reporting Data Collection, which is
available on the CMS Hospice Quality Reporting – Spotlight & Announcements
web site at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Spotlight.html in the “Downloads” section
at the bottom of the page.
Conventions Used In This Guide
Conventions and terminology used in this guide are defined as follows:
Bold

The names of web pages and buttons on web pages are bolded.

Italics

The names of fields, page tabs, and field options are italicized.

Underline

Hyperlinks (links) to web pages or web or email functions are
underlined.

CCN

CMS Certification Number, also known as the Medicare provider
number. CCN is a 6-digit number.

Check Box

A field on a web page that presents multiple options for you to
select. Associated with each option is a small box. Point to and
click on the box to select the associated option. A check mark
appears in the box when the option is selected. You may “check”
multiple check box options.

Click

Press and release the left mouse (or other pointing device) button,
without moving the pointer, to select an item or activate a link.

CMS

Centers for Medicare & Medicaid Services. Also known as
Medicare.

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Cursor

A blinking vertical line (|) that indicates where a character you type
on the keyboard appears on the computer screen.

Drag

Point to an object and press the left mouse (or other pointing
device) button as you move the mouse to reposition the object on
the page.

Drop-down
List

A field on a web page that presents a list of options. Click on the
arrow associated with the field to view the available options.

Field

Object on a web page into which a user enters information or
selects options. Text boxes, check boxes, radio buttons, and
drop-down lists are types of fields.

Hover

Move your mouse (or other pointing device) pointer so that it is
pointing to an item on a web page and pause for a moment.

Point

Move the mouse (or other pointing device) pointer until the tip of
the arrow/pointer rests on an object on a web page.

Provider

An entity providing health care services such as hospice.

Radio
Button

A field on a web page that presents mutually exclusive options,
such as Yes or No. Associated with each option is a circle. Point
to and click on a circle to select the associated option. The circle
is filled in for a selected option and empty for an unselected
option.

Scroll Bar

If the web page you are viewing does not entirely fit into your
viewing area, scroll bar(s) (horizontal, vertical, or both) are
included on the page so that you may reposition the content of the
page. Each scroll bar is a narrow rectangular area that includes
arrows on both ends and a slider bar in between. To reposition
the content of a page with a scroll bar, click on either arrow (in the
appropriate direction) or drag the slider bar.

Select

Point to and click on a button or a link to activate it, or on check a
check box to “check” it, or on a drop-down list option to choose it.

NOTE: Special notes or suggestions to the user display in a bordered box,
similar to this one.

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Printing
You may print any page of the Hospice Quality Reporting Data Entry Site by
using the print function of your browser. Either select the printer icon from the
browser tool bar or select File and then Print… from the menu bar.
Help
Field Help
Online help is available for many of the Hospice Quality Reporting Data Entry
Site fields. Hover your on-screen pointer over a field to view a brief description of
that field.
Technical Help Desk
You may contact the QTSO Helpdesk via phone at 1-877-201-4721 or email at
[email protected] if you have questions about using the Hospice Quality Reporting
Data Entry Site. Technical Help Desk hours are 7:00 am – 7:00 pm Central
Time.
The Technical Help Desk is available to assist providers with issues pertaining to:
•

Finding/locating the Data Entry website

•

Username/password issues

•

Website difficulty/error messages

Data Entry Site Availability
The Hospice QRP data entry site is available January 1, 2013, through April 1,
2013. Providers will not be able to access the data entry site outside of this date
range, nor will the link to the site be available outside of this date range.
Providers should check the “Spotlight and Announcements” section of the
Hospice QRP CMS page for announcements regarding the data entry site
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Spotlight.html.
NOTE: Accounts established during the voluntary reporting initiative are no
longer open. Each person submitting HQRP data in 2013 must register for an
account specifically for the new reporting period.

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BACKGROUND
Section 1814(i)(5) of the Social Security Act (the Act) added by section 3004 of the
Patient Protection and Affordable Care Act, Pub. L. 111-148, enacted on March 23,
2010 (Affordable Care Act), authorizes the Secretary to establish a quality reporting
program for Hospices. Section 1814(i)(5)(A)(i) of the Act requires that beginning
with FY 2014, and for each subsequent FY, the market basket update shall be
reduced by two percentage points for any provider that does not comply with the
quality data submission requirements with respect to that fiscal year.
To meet the quality reporting requirements set forth in the Hospice Wage Index Final
Rule (76 F.R. Vol. 76, No. 150, August 4, 2011), hospices are to report quality data
pertaining to two quality measures:
1. A structural measure titled “Participation in a Quality Assessment and
Performance Improvement (QAPI) Program that Includes at Least Three
Quality Indicators Related to Patient Care” and;
2. The NQF-endorsed #0209 pain measure, which is further described as the
percentage of patients who report being uncomfortable because of pain at the
initial assessment (after admission to hospice services) who report pain was
brought to a comfortable level within 48 hours.
To meet the quality reporting requirements for the FY 2014 payment determination,
hospice providers shall collect data on the two measures from October 1, 2012,
through December 31, 2012. The data collected during this period must be reported
to CMS by no later than January 31, 2013, for the structural measure and April 1,
2013, for the NQF #0209 pain measure. Thereafter, all subsequent hospice data
collection periods will be based on a calendar-year. Data submission deadlines will
occur in the year immediately following the collection period.
The Hospice Quality Reporting Data Entry Site allows hospice providers to submit
quality data to CMS for the data collection period starting October 1, 2012, through
December 31, 2012, and each year thereafter.

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WHO, WHAT, WHEN & HOW
Who:
All hospice providers that are Medicare certified (have a valid CCN, or Medicare
Provider Number) as of October 1, 2012, are required to collect and submit data to
CMS.
For Hospices with Multiple Locations:
•

Hospices will report data for both measures to CMS on a per-CCN basis.
○ Hospice providers with multiple locations, sharing one CCN, should
aggregate facility-level data from all locations so the data entered on
the CMS data entry site represent data for the single CCN.

Eligible patients for measure reporting include the following:
•

All payers (Medicare, Medicaid, and private payers) and

•

All hospice provider settings (inpatient, home care, nursing home, assisted
living facility, etc.)

What:
Hospice providers will report two measures. These measures are as follows:
•

A structural measure: provides CMS with general information about the
kinds of patient care-related quality indicators (QIs) used in hospice
organizations’ QAPI programs. It is intended to reflect which domains and
topics of care providers include in their QAPI programs. Hospice
providers will select the domains/topics of care for which they have at
least one quality indicator using a drop-down menu. No numerical data or
performance scores will be reported for the structural measure.

•

The NQF #0209 Pain Measure: calculates the percentage of patients who
report being uncomfortable because of pain at the initial assessment (after
admission to hospice services) who report that pain was brought to a
comfortable level within 48 hours. Hospice providers will submit 7 facilitylevel, aggregate data elements to CMS for the NQF #0209 Pain Measure
reporting.

When:
There are two separate reporting deadlines for submitting the required data to CMS:

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•

The structural measure must be submitted no later than January 31, 2013.

•

The NQF #0209 Pain Measure must be submitted no later than April 1,
2013.

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The data collection period for both measures is October 1 – December 31, 2012.
How:
•

Hospice providers will collect data for both measures October 1, 2012 –
December 31, 2012.

•

Hospice providers will enter their data online and submit them to CMS using
the data entry site.

•

The Hospice QRP Data Entry Site is available January 1, 2013 – April 1,
2013. Providers will not be able to access the data entry site outside of this
date range, nor will the link to the site be available outside of this date range.
Providers should check the “Spotlight and Announcements” section of the
Hospice QRP CMS page for announcements regarding the data entry site
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Spotlight.html

•

Hospice providers may utilize vendors for their individual hospice provider
data submission, but CMS will not support batch submissions involving
scripting or database imports for multiple hospice providers from vendors.

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ACCESS THE HOSPICE QUALITY REPORTING DATA ENTRY SITE
NOTE: Prior to accessing the Hospice Quality Reporting Data Entry Site, please
ensure that you have read and understood the data collection and reporting
requirements defined in the User Guide for Hospice Quality Reporting Data
Collection. This document is available on the CMS Hospice Quality Reporting –
Spotlight & Announcements web site at http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/Hospice-QualityReporting/Spotlight.html in the “Downloads” section at the bottom of the page.
To access the Hospice Quality Reporting Data Entry website:

1.

Visit the CMS Hospice Quality Reporting page (Figure 1) at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Data-Submission.html.

Figure 1.

2.
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Hospice Quality Reporting Page at CMS.gov

In the Related Links section of the Hospice Quality Reporting Data
Submission page, click on (select) the Hospice Quality Reporting Data
Entry link. The Home page of the Hospice Quality Reporting Data Entry
Site (Figure 2) opens.
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Figure 2.

Hospice Quality Reporting Data Entry Site Home Page

NOTE: It might be helpful to bookmark or add this page to your Favorites for
easy future access.
The Home page of the Hospice Quality Reporting Data Entry Site includes the
following items:
•

Register – a link to the Register an Account page where the person
submitting Hospice QRP data for a hospice with a unique CCN must
register for a user account. During the registration process you create the
user name and password with which you log in to the Hospice Quality
Reporting Data Entry Site.

NOTE: Accounts established during the voluntary reporting initiative are no
longer open. Each person submitting HQRP data in 2013 must register for an
account specifically for the new reporting period.

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•

Login – a link to the Log In page where registered users log in to the
Hospice Quality Reporting Data Entry Site.

•

Provider Info – a tab that, once you are registered and logged in to the
Hospice Quality Reporting Data Entry Site, presents the first of a series of
pages on which you enter your provider-identifying information and quality
reporting data. If you have not yet logged in to the Hospice Quality
Reporting Data Entry Site, the Provider Info tab presents the Log In page.

•

About – a tab that presents links to information on the web about the
Affordable Care Act and Hospice Quality Reporting.

•

CMS Hospice Quality Reporting Program website – a link to the Hospice
Quality Reporting page on the CMS web site.

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REGISTER AND ACTIVATE YOUR ACCOUNT
Before you can log in to the Hospice Quality Reporting Data Entry Site and enter
Hospice QRP data, you must first register for and activate a user account.
NOTE: Accounts established during the voluntary reporting initiative are no
longer available. Each person submitting Hospice QRP data in 2013 must
register for an account specifically for the current reporting initiative.
To register for a user account for the Hospice Quality Reporting Data Entry Site,
perform the following:

1.

In the upper-right corner of the page, point to and click on the Register
link. The Register an Account page (Figure 3) is presented.

Figure 3.

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Register An Account Page

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The Register an Account page presents the following fields:
♦
♦
♦
♦
♦
♦
♦
♦
♦

CCN
Hospice Name
Your First Name
Your Last Name
Hospice Phone Number
Email Address
Confirm Email Address
Password
Confirm Password

2.

Point to and click in the CCN field. Enter your provider CMS Certification
Number and press the Tab key. The cursor advances to the Hospice
Name field.

3.

Enter your provider name in the Hospice Name field and press the Tab
key. Complete the remaining fields on the Register an Account page in
this manner.

NOTE: To maintain password privacy, when you type in the Password and
Confirm Password fields, a solid circle displays for each character you type. If
the characters you type in the Password and Confirm Password fields do not
match exactly, an error occurs. Re-type your password in both fields to proceed.

4.

When all fields are complete, select (click on) the Register button at the
bottom of the page. The Thanks for Registering page (Figure 4) is
presented.

NOTE: Please commit your password to memory for future use. The password
is case-sensitive. To log in to the system, you must enter your email address
and password exactly the way you entered it on the Register an Account page.

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Figure 4.

Thanks For Registering Page

The Thanks for Registering page indicates that an email message is on its way
to the email address you entered on the Register an Account page. This email
will provide a link and instructions for you to activate your account.

5.

Access the email account you registered and open the email message.

6.

Select (click on) the activation link in the email. Your account is now
active. The Hospice Quality Reporting Data Entry Site Log In page
(Figure 5, below) is presented.

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LOG IN TO THE HOSPICE QUALITY REPORTING DATA ENTRY SITE
The Log In page (Figure 5) is automatically presented to first-time users when
they activate their account.
Returning registered users select the Login link in the upper right corner of the
Home page of the Hospice Quality Reporting Data Entry Site (Figure 2, above) to
log in.
Figure 5.

Log In Page

Point to and click in the Email Address field. Enter the email address you
registered and press the Tab key. The cursor advances to the Password field.
Enter the password you created when you registered your account and select the
Log in button at the bottom of the page.
NOTE: If you forgot your password, select the Forgot password? link at the
bottom of the page and follow the instructions for requesting a new password. If
you do not remember the email address you used when you registered for an
account, or that email address is no longer available, please contact the QTSO
Helpdesk for assistance by email at [email protected] or by phone at 1-877-2014721.
In response to a successful login to the Hospice Quality Reporting Data Entry
Site, the Hospice Provider Information page (Figure 6, below) is presented.

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ENTER QRP MEASURE DATA
Hospice Provider Information
Upon successful login to the Hospice Quality Reporting Data Entry Site, the
Hospice Provider Information page (Figure 6) is presented so that you may
enter your Hospice QRP measure data, beginning with some provider-identifying
information.
Figure 6.

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Hospice Provider Information Page (Partial)

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NOTE: The first time you log in to the system several of the fields on the
Hospice Provider Information page are pre-filled with information you provided
when you registered for an account. Modify these fields only as necessary.
The Hospice Provider Information page includes the following:
•

Instruction text: Please provide your CMS Certification Number (CCN).
○ Field: CCN

•

Instruction text: Enter the legal name and mailing address of your hospice
organization.
○ Field: Business Name
○ Field: Mailing Address
○ Field: Mailing Address Line 2 (no label)
○ Field: City
○ Drop-down list: State
○ Field: ZIP Code

•

Instruction text: Enter the physical address of your hospice organization.
○ Check box: Same As Mailing Address
○ Field: Physical Address
○ Field: Physical Address Line 2 (no label)
○ Field: City
○ Drop-down list: State
○ Field: ZIP Code

•

Instruction text: Enter the business telephone of your hospice
organization during regular business hours. Use numerals only, no
dashes, spaces, or other characters.
○ Field: Business Telephone Number

•

Instruction text: Enter the contact information for a person at your hospice
organization who will be able to answer questions about the data entered
on this website. This may or may not be the individual who completes the
data entry on this data entry website.
○ Field: Contact Name
○ Field: Contact Phone
○ Field: Contact Email

•

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Button: Next>>

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To enter the requested information about your hospice:

1.

Point to and click in the first field that is empty or must be modified. Enter
the requested information and press the Tab key. The cursor advances to
the next field. Continue in this manner with the remaining fields on the
Hospice Provider Information page.

NOTE: The State field provides a drop-down list of states from which to choose.
Click on the down arrow associated with the State field to view an expanded list
of states. If your state is not in view, use the vertical scroll bar along the right
side of the list to scroll down through the states. When your state is visible, point
to and click on it to select it.

NOTE: If the hospice’s physical address is the same as its mailing address,
check (click on) the Same As Mailing Address check box. You may then skip the
physical address fields. The mailing address information you entered above will
be used for both the mailing and physical addresses.

2.

When all fields are complete, select (click on) the Next>> button at the
bottom of the page. The Measure Data Entry Links And Submission
Status page (Figure 7) is presented.

NOTE: The next and subsequent times you log in to the system, the information
you entered on the Hospice Provider Information page is displayed. You need
not enter it again. Simply select the Next>> button to proceed.

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Figure 7.

Measure Data Entry Links And Submission Status Page

The Measure Data Entry Links And Submission Status page presents the
following links with which you may independently access the Hospice Quality
Reporting Data Entry Site pages to enter specific QRP measure data:
•

The Structural Measure: QAPI Program Information

•

NQF #0209 Pain Measure

Noted for each measure are the dates of the submission period and the status of
your data entry/submission.
Submission statuses include:
•

No Data Entered – you have not entered and/or saved any measure data.

•

Data Saved Not Submitted – you have entered and saved measure data,
but not submitted the data or provided attestation.

•

Data Submitted and Attested To – you have entered, saved, and
submitted measure data and provided attestation.

NOTE: Submitting measure data and providing attestation are two distinct steps.
Both of these steps are required for your submission to CMS to be complete and
are detailed later in this guide. Your measure submission status does not
change to “Data Submitted and Attested To” until you complete both steps.

3.
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Select (point to and click on) the link that corresponds to the HQRP
measure data you wish to enter.
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The Structural Measure
When you select the link, The Structural Measure: QAPI Program Information, on
the Measure Data Entry Links And Submission Status page, the Structural
Measure Information page (Figure 8) is presented.
Figure 8.

Structural Measure Information Page (Partial)

The Structural Measure Information page presents three questions, as follows:
NOTE: If you completed the Appendix A worksheet provided in the User Guide
for Hospice Quality Reporting Data Collection refer to it now for the answers to
the Structural Measure questions.
If you are unsure how to answer these questions, refer to the User
Guide for Hospice Quality Reporting Data Collection, which is available on the
CMS Hospice Quality Reporting – Spotlight & Announcements web site at
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Spotlight.html in the “Downloads” section
at the bottom of the page.

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•

Q1: Does your hospice have a Quality Assessment and Performance
Improvement (QAPI) program that includes three or more quality
indicators (QIs) related to patient care?
Provided for Q1 are radio buttons associated with Yes and No answers to
the question. Select (click on) the radio button indicating your response.

•

Q2: If your hospice’s QAPI program includes at least one patient carerelated quality indicator, include each indicator using the form provided
below.
The topics with which your hospice’s quality indicators may be associated
are provided as options for you to select for Q2. For quick access, topics
are organized into the following domains:
○ Domain 1: Patient Safety
○ Domain 2: Physical Symptom Management
○ Domain 3: Care Coordination and Transitions
○ Domain 4: Patient/Family Preferences
○ Domain 5: Communication and Education
○ Domain 6: Patient/Family Experience/Ratings of Care and/or Services
○ Domain 7: Spiritual
○ Domain 8: Structure and Process of Care
○ Domain 9: Psychosocial
○ Domain 10: Grief, Bereavement, and Emotional Support
Topics in some domains are further organized into sub-domains.
A check box is provided for each topic. Check (click on) the check boxes
for those topics for which your hospice’s QAPI program includes at least
one patient care-related quality indicator.

•

Q3: Please indicate the data source(s) for your QAPI indicators. Check all
that apply.
Response options provided for Q3 are:
○ Electronic Medical Record (EMR)
○ Paper Medical Record
○ Family survey/questionnaire
○ Patient survey/questionnaire
○ Incident report/log

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The Structural Measure Information page includes the following buttons at the
bottom of the page:
•

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