Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	New	Available
Form CMS-10210 Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)	Form	Removed	Available
Form CMS-10210 Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)	Form	Removed	Available
CMS 10210 Supporting Statement A.docx	Supporting Statement A	Uploaded 2012-10-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	New
178678	Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)	Form	Removed
178677	Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)	Form	Removed

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 201210-0938-002
Status: Historical Active	Previous ICR Reference No: 200803-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/20/2013
	Date Received in OIRA: 10/02/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved
Responses	17,600	0	0
Time Burden (Hours)	6,750,000	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Hospital Inpatient Quality Reporting Program (IQR) program was first established to implement section 5001(b) of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) (Pub. L. 108-173), which authorized CMS to pay hospitals that successfully reported quality measures a higher annual update to their payment rates. It builds on a voluntary Inpatient Quality Reporting program which remains in effect. The Hospital IQR program formerly known as the Reporting Hospital Quality Data for Annual Payment Update program, began with an initial set of 10 measures. Section 5001(a) of the Deficit Reduction Act of 2005 (DRA) (Pub. L. 109-171) revised the mechanism used to update the standardized amount for payment for hospital inpatient operating costs. This is reflected in Sections 1886(b)(3)(B)(viii)(I) and (II) of the Social Security Act which provide that the annual payment update (APU) will be reduced for any "subsection (d) hospital" that does not submit certain quality data in a form and manner, and at a time, specified by the Secretary. Section 5001(a) of the DRA also expanded the scope of IQR, requiring CMS to add new measures. Sections 1886(b)(3)(B)(viii)(III) through (V) of the Social Security Act, required CMS to "adopt the baseline set of performance measures as set forth in the November 2005 report by the Institute of Medicine of the National Academy of Sciences", instructed the Secretary to "add other measures that reflect consensus among affected parties", and allowed the Secretary to "replace any measures or indicators in appropriate cases". When adding new measures, the law required CMS when "feasible and practical" to select measures put forward by "one or more national consensus building entities".

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Authorizing Statute(s): PL: Pub.L. 109 - 171 5001(a) Name of Law: Hospital Quality Improvement
   PL: Pub.L. 108 - 173 50019b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   US Code: 11 USC 148-3001 Name of Law: Affordable Care Act
  

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

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 53258	08/31/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 53258	08/31/2012
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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	Hospital Data Validation ,   Reconsideration Request Online ,   Reconsideration Request Paper ,   Extroadinary Circumstance Online ,   Extroadinary Circumstance Paper ,   Reconsideration Request Part 2 ,   Decline to Participate ,   Data Accuracy and Completeness ,   Notice of Participation ,   HAI Exception Online ,   HAI Exception Paper
Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)	CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210	Cart Summary ,   Oryx ,   Qnet ,   HIPAA Compliance ,   Notice of Participation
Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPPS Annual Payment Update (Surgical Care Improvement Project & Mortality Measures)	CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210	Cart Summary ,   Oryx ,   Qnet ,   HIPAA Compliance ,   Notice of Participation

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	17,600	0	0	17,600	0	0
Annual Time Burden (Hours)	6,750,000	0	0	6,531,236	218,764	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: As shown above, this program has significantly increased the number of measures included in its data collection requirements. These increases support adherence to: Section 1886(b)(3)(B)(viii) of the SSA, which required the expansion of the IQR program between FY 2008-2012; Section 3013 of ACA which modified Section 931 of the Public Health Service Act by requiring CMS "identify, not less often than triennially, gaps where no quality measures exist and existing quality measures that need improvement, updating or expansion"; and Section 1886(o) of the SSA which requires CMS to use data reported through the IQR for its VBP program.

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Annual Cost to Federal Government: $2,550,000

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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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: 10/02/2012

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