CMS-10210 IQR Measure Exception Form

Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Reporting Programs
Measure Exception Form for PC, ED, and HAI Data Submission

This Measure Exception Form must be renewed at least annually.
Please Note: Per National Healthcare Safety Network (NHSN) guidelines for 2015 discharges,
facilities are now required to report facility-wide Catheter-Associated Urinary Tract Infection
(CAUTI) and Central Line-Associated Bloodstream Infection (CLABSI) for the Hospital Inpatient
Quality Reporting (IQR) Program. However, measure exceptions for CAUTI and CLABSI may
still be filed for the Hospital Value-Based Purchasing (VBP) and Hospital-Acquired Condition
(HAC) Reduction Programs only, as these programs may still use only the specified Intensive
Care Unit (ICU) locations. A measure exception for Surgical Site Infection (SSI) may be filed for
all three programs (IQR, VBP, and HAC Reduction).
Fields marked with an asterisk (*) are required.

Specify the applicable quarter(s) for the Measure Exception request(s).
*IPPS Measure Exception Information (select all that apply)
Please Note: ED applies to Hospital IQR Program only.
Emergency Department (ED-1: Median Time from ED Arrival to ED Departure for
Admitted ED Patients and ED-2: Admit Decision Time to ED Departure Time for Admitted
Patients)
Hospital has no Emergency Department and does not provide emergency care.
Calendar Year (YYYY) ________
January 1 through March 31
July 1 through September 30

April 1 through June 30
October 1 through December 31

Please Note: PC-01 applies to Hospital IQR and VBP Programs only.
Perinatal Care (PC-01: Elective Delivery Prior to 39 Completed Weeks Gestation)
Hospital has no Obstetrics Department and does not deliver babies.
Calendar Year (YYYY) ____________
January 1 through March 31
July 1 through September 30

April 1 through June 30
October 1 through December 31

Please Note: SSI applies to Hospital IQR, VBP, and HAC Reduction Programs.
SSI – Colon Surgery (SSI-Colon and SSI-Abdominal Hysterectomy) **
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 of procedures performed _____
Exclusion requested for Calendar Year (YYYY) _______

February 2015

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Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Reporting Programs
Measure Exception Form for PC, ED, and HAI Data Submission
Please Note: CAUTI and CLABSI apply to Hospital VBP and HAC Reduction Programs only.
Catheter-Associated Urinary Tract Infection (CAUTI)
Hospital has no Adult or Pediatric ICU locations.
Calendar Year (YYYY) ____________
January 1 through March 31
July 1 through September 30

April 1 through June 30
October 1 through December 31

Please Note: CAUTI and CLABSI apply to Hospital VBP and HAC Reduction Programs only
Central Line-Associated Bloodstream Infection (CLABSI)
Hospital has no Adult, Pediatric, or Neonatal ICU locations.
Calendar Year (YYYY) ____________
January 1 through March 31
July 1 through September 30

April 1 through June 30
October 1 through December 31

**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 are eligible for the SSI
Measure Exception. 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 NHSN at http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf.

*Facility Contact Information
*CMS Certification Number (CCN): ________________________________________________
*Facility Name: _______________________________________________________________
*CEO/Designee Last Name: _____________________________________________________
*CEO/Designee First Name: _____________________________________________________
*Title: ______________________________________________________________________
*CEO/Designee Email Address: __________________________________________________
*CEO/Designee Telephone Number: ___-___-____ ext. __________
I hereby certify that the facility meets the exception criteria and therefore has no data to submit
related to the PC, ED, SSI, CLABSI, or CAUTI measures, as indicated on this form.
*Name: _____________________________________________________________________
*Position: ___________________________________________________________________
February 2015

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Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Reporting Programs
Measure Exception Form for PC, ED, and HAI Data Submission

Submission Instructions
Complete and submit this form via the QualityNet Secure Portal, Secure File Transfer
“WAIVER EXCEPTION WITHHOLDING” group. If unable to submit via Secure File
Transfer, please submit via email to [email protected] or secure fax to 877-789-4443.
Following receipt of this request form, CMS will provide an email acknowledgement that the
request has been received. Once a determination has been made, CMS will provide the formal
decision regarding the request.
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 09381022.The time required to complete this information collection is estimated to average 10 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 estimates(s) or
suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1650.

February 2015

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