CMS-10431 SCIP Pop Sample Application

PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program

Web-Based Application for Surgical Care Improvement Project (SCIP) Measures

Online Data Entry Tool Content for FY 2016 and Subsequent Years

Overview

This document provides instructions for using the CMS online web application for reporting the Population and Sampling data for the Surgical Care Improvement Project (SCIP) Measures.

The Population and Sampling application enables a PPS-Exempt Cancer Hospital user or their contracted vendor to enter the population data of Medicare and non-Medicare patients that meet the inclusion criteria for the Surgical Care Improvement Project (SCIP) measure set. The user or their contracted vendor can also indicate if they are submitting all of the records that meet the inclusion criteria, or if sending a sample, they can identify the frequency of sampling and the number of records that will be included in the sample.

CMS uses both Medicare claims counts and hospital self-reported total population (Medicare and Non-Medicare combined) counts to assess hospital compliance with submitting patient-level data in accordance with the minimum sampling requirements. The larger of the two numbers for each measure set/SCIP strata will be used to determine compliance with sampling requirements.

Accessing the Web-Based Application

The user enters their assigned User ID and password to access the secure site and information for their individual hospital.

Figure 1 Sign In

Manage Measures

After selecting the “View / Edit Population and Sampling” link under Manage Measures, the user selects the Reporting Period and selects the [Continue] button:

Figure 2 View/Edit Population & Sampling Selections

Sampling Frequency Selection

The user will insert their sampling frequency of Quarterly or Not Sampled.

The Surgical Care Improvement Project (SCIP) measure set is divided into 8 strata. Based on the selection above, the user will enter the population and sample size for each of the 8 stratum.

Reporting – Initial Inpatient Population and Sample Size

The reporting is identified as Medicare and Non-Medicare. The examples below are for a hospital performing quarterly sampling (Strata 1 through 5) and Not Sampling (Strata 6):

Figure 3 SCIP - Strata 1 (Coronary Artery Bypass Graft)

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	29	22	16	10	77
Non-Medicare	14	11	14	39	78
Total	43	33	30	49	155

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	10	11	11	9	41
Non-Medicare	6	9	11	11	37
Total	16	20	22	20	78

Figure 4 SCIP - Strata 2 (Other Cardiac Surgery)

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	19	12	14	20	65
Non-Medicare	13	17	11	39	80
Total	32	29	25	59	145

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	7	0	10	15	32
Non-Medicare	12	13	10	18	53
Total	19	13	20	33	85

Figure 5 SCIP - Strata 3 (Hip Arthroplasty)

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	19	6	14	10	49
Non-Medicare	13	17	11	39	80
Total	32	23	25	49	129

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	10	6	11	9	36
Non-Medicare	10	14	10	20	54
Total	20	20	21	29	90

Figure 6 SCIP - Strata 4 (Knee Arthroplasty)

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	37	37	25	20	119
Non-Medicare	15	16	11	10	52
Total	52	53	36	30	171

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	28	25	22	17	92
Non-Medicare	12	10	9	7	38
Total	40	35	31	24	130

Figure 7 SCIP - Strata 5 (Colon Surgery)

Sample Frequency: Quarterly

Initial Inpatient Population

Initial Inpatient Population	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	37	33	35	45	150
Non-Medicare	8	10	9	5	32
Total	45	43	44	50	182

Sample Size

Sample Size	Quarter 1	Quarter 2	Quarter 3	Quarter 4	Total
Medicare	20	18	9	25	72
Non-Medicare	2	4	4	2	12
Total	22	22	13	27	84

22

Figure 8 SCIP - Strata 6 (Hysterectomy)

Sample Frequency: Not Sampling

Not Sampled Patient Population	Number
Total Initial Patient Population	30
Medicare Initial Patient Population	11
Non-Medicare Initial Patient Population	19

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1175. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26

PCHQR Program 04/08/2014 Page 6 of 6