CMS-10431 SCIP Pop Sample Application

PPS-exempt Cancer Hospital Quality Reporting (PCHQR) Program

Form SCIP PopSample_application April 17 2014

PPS-exempt Cancer Hosptital Quality Reporitng (PCQR) Program

OMB: 0938-1175

Document [docx]
Download: docx | pdf

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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorDavis, Rhonda
File Modified0000-00-00
File Created2021-01-25

© 2024 OMB.report | Privacy Policy