CMS-10210 HAI Exception Online

Centers for Medicare & Medicaid Services (CMS)
Hospital Inpatient Quality Reporting (IQR) Program
Healthcare Associated Infection (HAI) Exception Form
This exception must be renewed at least annually.
Specify the calendar year and applicable quarter(s) for the specified National Healthcare Safety Network (NHSN) HAI
Measure exception request(s).
* Indicates required fields
*HAI Measure Exception Information (The exception(s) you are requesting must be selected.)
Select all that apply.
Calendar Year Select

Catheter-Associated Urinary Tract Infection
(CAUTI)
Select this option if the hospital has no Adult or Pediatric
Intensive Care Unit (ICU) locations.

January 1 through March 31
April 1 through June 30
July 1 through September 30
October 1 through December 31

Calendar Year Select

Central Line-Associated Bloodstream Infection
(CLABSI)
Select this option if the hospital has no Adult, Pediatric or
Neonatal Intensive Care Unit locations.

January 1 through March 31
April 1 through June 30
July 1 through September 30
October 1 through December 31

Calendar Year prior to Reporting Year Select

Surgical Site Infection (SSI)
Select this option if the hospital performed a combined
total of 9 or fewer colon surgeries and abdominal
hysterectomies in the calendar year prior to the reporting
year.

Number of procedures performed
Exclusion requested for Calendar Year Select

*I have reviewed NHSN definitions for (select all that apply):
ICU locations

Neonatal ICU locations

Specified colon surgery and abdominal hysterectomy

An intensive care unit (ICU) is defined as:
The Centers for Disease Control and Prevention (CDC)-defined designation given to a patient care area housing
patients who have similar disease conditions or who are receiving care for similar medical or surgical specialties.
Each facility location that is monitored is "mapped" to one CDC Location. The specific CDC Location code is
determined by the type of patients cared for in that area according to the 80% Rule. That is, if 80% or more of the
area's patients are of a certain type (e.g., intensive care unit patients) then the area is designated as that type of
location (in this case, an intensive care unit).
Conversely, if fewer than 80% of the patients in any hospital unit do not receive intensive observation, diagnosis, and
therapeutic procedures for critical illness, i.e. are not ICU patients, then the hospital by definition has no ICU and is
eligible to complete the "Healthcare Associated Infection (HAI) Exception" form consistent with CDC's "80% Rule"
and CMS Hospital IQR policy guidance.

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Specified colon and abdominal hysterectomy surgical procedures:
Only hospitals that performed 9 or fewer of any of the specified colon surgeries and abdominal hysterectomies
combined in the calendar year prior to the reporting year. The NHSN Operative Procedure Category Mappings to
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes (Table 1
extract) is located on the NHSN website.
Facility Contact Information
*CMS Certification Number (CCN)
*CEO/Designee Last Name
*Title

*Facility Name
*CEO/Designee First Name
*CEO/Designee E-Mail Address

*CEO/Designee Telephone Number

Ext.

Additional Comments

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