CMS-10210 Healthcare Associated Infection Exception Form

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. This exception form must be submitted no later than 11:59 p.m. Pacific Standard Time on the date of the quarterly submission deadlines for which the exception is requested. Refer to the Hospital Inpatient Quality Reporting (IQR) Program Important Dates document posted on QualityNet.

Specify the calendar year and all applicable quarter(s) for the specific 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

 Catheter-Associated Urinary Tract Infection (CAUTI)
Hospital has no Adult or Pediatric Intensive Care Unit (ICU) locations

Calendar Year (YYYY)_____________

 January 1 through March 31  April 1 through June 30

 July 1 through September 30  October 1 through December 31

 Central Line-Associated Bloodstream Infection (CLABSI)
Hospital has no Adult, Pediatric or Neonatal Intensive Care Unit (NICU) locations

Calendar Year (YYYY)_____________

 January 1 through March 31  April 1 through June 30

 July 1 through September 30  October 1 through December 31

 Surgical Site Infection (SSI)

Hospital performed a combined total of 9 or fewer colon surgeries and abdominal hysterectomies in the calendar year prior to the reporting year.

Calendar Year prior to reporting year (YYYY) ________ Number procedures performed _____

Exclusion requested for Calendar Year (YYYY) _____________

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

 ICU locations  NICU locations  Specified colon surgery and abdominal hysterectomies

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.

Specified colon and abdominal hysterectomy surgical procedures:

Only hospitals that performed 9 or fewer of any of the specified colon and abdominal hysterectomy 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): _______________________________________________________

*Facility Name: _______________________________________________________________________

*CEO/Designee Last Name: _____________________________________________________________

*CEO/Designee First Name: _____________________________________________________________

*Title _______________________________________________________________________________

*CEO/Designee E-Mail Address: _________________________________________________________

*CEO/Designee Telephone Number: ______-______-_______ ext. __________

Additional Comments:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

I hereby certify that the facility meets the exception criteria and therefore has no data to submit related to the specified HAI measure(s)

Name ___________________________________

Position _________________________________

Submit the completed form to CMS via the My QualityNet Global File Exchange group, “IQR NHSN Exception Requests”.

05/29/2013 Page 2 of 2