CMS-10390 Crosswalk

APPENDIX B: Changes to HQRP Data Submission Form

General Changes
Change		Rationale
The Hospice Data Submission Form is renamed Hospice Item Set. The Hospice Data Submission Form - NQF #0209 Pain Measure is renamed Hospice Item Set - Admission. The Hospice Data Submission Form - Structural Measure is renamed Hospice Item Set - Discharge.		Retiring non-NQF-endorsed structural measure and NQF #0209 Pain Measure. Replacing items related to these measures with items needed to calculate newly endorsed quality measures.
Items Eliminated/Replaced
Section or Item		Form	Rationale
Facility Provider Identification		Structural Measure, NQF #0209 Pain Measure	A0100 Facility Provider Numbers replaces this item (see Items Added). The change is needed for item harmonization across item sets.
Part 1. Structural Measure		Structural Measure	Retiring non-NQF-endorsed quality measure.
Q1. Does your hospice have a Quality Assessment and Performance Improvement (QAPI) program that includes three or more quality indicators related to patient care?		Structural Measure	Retiring non-NQF-endorsed quality measure
Q2. If your hospice’s QAPI program includes at least one patient care related quality indicator, include each indicator using the form provided below.		Structural Measure	Retiring non-NQF-endorsed quality measure
Q3. Please indicate the data source(s) for your QAPI indicators.		Structural Measure	Retiring non-NQF-endorsed quality measure
Part 2. NQF #0209 Pain Measure		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure. Items in this section will be replaced with items J0900 Pain Screening and J0910 Comprehensive Pain Assessment which are needed to calculate newly endorsed quality measures addressing pain (See Items Added).
1. Enter the number of admissions during the data collection period (October 1, 2012 through December 26, 2012)		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.
2. Pain Measure Denominator: Enter the number of patients who answered YES to the question “are you uncomfortable because of pain?” at the initial assessment (after admission to hospice services) during the data collection period		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.

Items Eliminated/Replaced
Section or Item		Form	Rationale
3. Enter the number of patients who answered NO to the question “are you uncomfortable because of pain?” at the initial assessment (after admission to hospice services) during the data collection period		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.
4. Enter the number of patients excluded.		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.
5. Pain Measure Numerator: Enter the number of patients who answered YES to the question “ was your pain brought to a comfortable level within 48 hours of the start of hospice care?” during the data collection period		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.
6. Enter the number of patients who answered NO to the question “ was your pain brought to a comfortable level within 48 hours of the start of hospice care?” during the data collection period		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.
7. Enter the number of patients unable to self report at follow up.		NQF #0209 Pain Measure	Retiring NQF #0209 Pain Measure.
Attestation		Structural Measure, NQF #0209 Pain Measure	Item Z0400 Signature(s) of Person(s) Completing the Record and Item Z0500 Signature of Person Verifying Record Completion replace this item (see Items Added). The change is needed for item harmonization across item sets.
Authorization for Hospice QRP Data Entry		Structural Measure, NQF #0209 Pain Measure	This item was for paper submissions. Going forward all submissions will be electronic.
Items Added
Section or Item Number	Section or Item Name	Form	Rationale
Section A	Administrative Data	Admission, Discharge	Items in this section are needed for record matching and management or to calculate newly endorsed quality measures.
A0050	Type of Record	Admission, Discharge	Needed for record matching and management
A0100	Facility Provider Numbers	Admission, Discharge	This item replaces the Facility Provider Identification section (see Items Eliminated/Replaced). It is needed for record matching and management.

Items Added
Section or Item Number	Section or Item Name	Form	Rationale
A0205	Site of Service at Admission	Admission, Discharge	Needed for quality measure maintenance and for harmonization with other item sets
A0220	Admission Date	Admission, Discharge	Needed for record matching and management and to calculate newly endorsed quality measures.
A0245	Date Initial Nursing Assessment Initiated	Admission	Needed to calculate newly endorsed quality measures
A0250	Reason for Record	Admission, Discharge	Needed for record matching and management
A0270	Discharge Date	Discharge	Needed for record matching and management and to calculate newly endorsed measures.
A0500	Legal Name of Patient	Admission, Discharge	Needed for record matching
A0600	Social Security and Medicare Numbers	Admission, Discharge	Needed for record matching
A0700	Medicaid Number	Admission, Discharge	Needed for record matching
A0800	Gender	Admission, Discharge	Needed for record matching
A0900	Birth Date	Admission, Discharge	Needed for record matching
A1000	Race/Ethnicity	Admission	Needed for quality measure maintenance and for harmonization with other item sets
A1802	Admitted From	Admission	Needed for quality measure maintenance and for harmonization with other item sets
A2115	Reason for Discharge	Discharge	Needed for quality measure maintenance and for harmonization with other item sets
Section F	Preferences	Admission	Items in this section are needed to calculate newly endorsed quality measures.
F2000	CPR Preferences	Admission	Needed to calculate newly endorsed quality measure
F2100	Other Life-Sustaining Treatments Preferences	Admission	Needed to calculate newly endorsed quality measure
F2200	Hospitalization Preference	Admission	Needed for ease of use of item set and for measure maintenance.

Items Added
Section or Item Number	Section or Item Name	Form	Rationale
F3000	Spiritual/Existential Concerns	Admission	Needed to calculate newly endorsed quality measure
Section I	Active Diagnoses	Admission	The item in this section is needed for quality measure maintenance and to harmonize with other item sets
I0010	Principal Diagnosis	Admission	Needed for quality measure maintenance and to harmonize with other item sets
Section J	Health Conditions	Admission	The items in this section are needed to calculate newly endorsed quality measures. Some will replace the NQF #0209 Pain Measure items. They are needed to calculate newly endorsed quality measures addressing pain and shortness of breath for hospice patients.
J0900	Pain Screening	Admission	Needed to calculate newly endorsed quality measures
J0910	Comprehensive Pain Assessment	Admission	Needed to calculate newly endorsed quality measure
J2030	Screening for Shortness of Breath	Admission	Needed to calculate newly endorsed quality measure
J2040	Treatment for Shortness of Breath	Admission	Needed to calculate newly endorsed quality measure
Section N	Medications	Admission	The items in this section are needed to calculate newly endorsed quality measures.
N0500	Scheduled Opioid	Admission	Needed to calculate newly endorsed quality measure
N0510	PRN Opioid	Admission	Needed to calculate newly endorsed quality measure and for ease of use of item set and for measure maintenance.
N0520	Bowel Regimen	Admission	Needed to calculate newly endorsed quality measure
Section Z	Record Administration	Admission, Discharge	The items in this section are needed for record management. They replace the Attestation item.
Z0400	Signature(s) of Person(s) Completing the Record	Admission, Discharge	Needed for record management
Z0500	Signature of Person Verifying Record Completion	Admission, Discharge	Needed for record management

Current as of February 22, 2013 Page 3 of 3