CMS-10250 Supporting Statement Part A 07_01_2015 CLEAN

Supporting Statement – Part A
Submission of Information for the Hospital Outpatient Quality Reporting (OQR) Program
A. Background
The Centers for Medicare and Medicaid Services’ (CMS’) quality reporting programs promote
higher quality and more efficient health care for Medicare beneficiaries. CMS has implemented
quality measure reporting programs for multiple settings, including for hospital outpatient care.
Section 109(a) of the Tax Relief and Health Care Act of 2006 (TRHCA) (Pub. L. 109-432)
amended section 1833(t) of the Social Security Act by adding a new subsection (17) that affects
the payment rate update applicable to Outpatient Prospective Payment System (OPPS) payments
for services furnished by hospitals in outpatient settings on or after January 1, 2009.
Section 1833(t)(17)(A) of the Act, which applies to hospitals as defined under section
1886(d)(1)(B) of the Act, requires that hospitals that fail to report data required for quality
measures selected by the Secretary in the form and manner required by the Secretary under
section 1833(t)(17)(B) of the Act will incur a reduction in their annual payment update (APU)
factor to the hospital outpatient department fee schedule by 2.0 percentage points.
Sections 1833(t)(17)(C)(i) and (ii) of the Act require the Secretary to develop measures
appropriate for the measurement of the quality of care furnished by hospitals in outpatient
settings. Such measures must reflect consensus among affected parties and, to the extent feasible
and practicable, must be set forth by one or more national consensus building entities. The
Secretary also has the authority to replace measures or indicators as appropriate and requires the
Secretary to establish procedures for making the data submitted available to the public. Such
procedures must provide the hospitals the opportunity to review such data prior to public release.
The CMS program established under these amendments is referred to as the Hospital Outpatient
Quality Reporting (OQR) Program.
Section 3014 of the Patient Protection and Affordable Care Act of 2010 (ACA) modified section
1890(b) of the Social Security Act to require CMS to develop quality and efficiency measures
through a “consensus-based entity.” To fulfill this requirement, the Measure Applications
Partnership (MAP) was formed to review measures consistent with these requirements. The
MAP is convened by the National Quality Forum (NQF), a national consensus organization, with
current organizational members including the American Association of Retired Persons (AARP),
America’s Health Insurance Plans, the American Federation of Labor-Congress of Industrial
Organizations (AFL-CIO), the American Hospital Association, the American Medical
Association, the American Nurses Association, the Federation of American Hospitals, and the
Pacific Business Group on Health. Nationally recognized subject matter experts are also voting
members of the MAP. CMS consulted with the MAP and received its formal recommendations
before identifying Hospital OQR Program measures to be included in the CY 2016 OPPS/ASC
proposed rule with comment period. This proposed rule also includes measures that were
adopted for the CY 2016 and subsequent years’ payment determinations. Prior to the ACA and
the formation of the MAP, CMS utilized consensus processes consistent with the authorizing
statute for selecting and adopting quality measures for the Hospital OQR Program.
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In implementing this and other quality reporting programs, CMS’ overarching goal is to support
the National Quality Strategy (NQS). The NQS is guided by three aims: better care, smarter
spending, and healthier people. The NQS was released by the U.S. Department of Health and
Human Services. The strategy was required under the ACA and is an effort to create national
aims and priorities to guide local, State, and national efforts to improve the quality of health care
in the United States.
The Hospital OQR Program strives to achieve these goals by making collected information
publicly available and fostering quality improvement. Taking into account the need to balance
breadth with minimizing burden, program measures address as fully as possible, the six domains
of measurement that arise from the National Quality Strategy: making care safer, strengthening
person and family engagement, promoting effective communication and coordination of care,
promoting effective prevention and treatment, working with communities to promote best
practices of healthy living, and making care affordable.
B. Hospital OQR Program Quality Measures and Forms
1. Introduction
Hospital OQR Program payment determinations are made based on Hospital OQR Program
quality measure data reported and supporting forms submitted by hospitals as specified through
rulemaking. To reduce burden, a variety of different data collection mechanisms are employed,
with every consideration taken to employ existing data and data collection systems. The
complete list of measures and data collection forms are organized by type of data collected and
data collection mechanism.
The Medicare program has a responsibility to ensure that Medicare beneficiaries receive health
care services of appropriately high quality, comparable to those provided under other payers. The
Hospital OQR Program seeks to encourage care that is both efficient and of high quality in the
hospital outpatient setting through collaboration with the hospital community to develop and
implement quality measures that are fully and specifically reflective of the quality of hospital
outpatient services.
2. CY 2015 Payment Determination
In the CY 2013 OPPS/ASC final rule with comment period, we finalized quality measures,
administrative processes, data submission, and validation requirements for the CY 2015 payment
determination.
HOSPITAL OQR PROGRAM MEASURES FOR THE CY 2015 PAYMENT
DETERMINATION
NQF No.
N/A
0288

Measure Name
OP-1: Median Time to Fibrinolysis
OP- 2: Fibrinolytic Therapy Received Within 30 Minutes of
ED Arrival
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Data Collection
Mode
Chart-abstracted
Chart-abstracted

NQF No.

Measure Name

0290

OP-3: Median Time to Transfer to Another Facility for Acute
Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
OP-6: Timing of Antibiotic Prophylaxis
OP-7: Prophylactic Antibiotic Selection for Surgical Patients
OP-8: MRI Lumbar Spine for Low Back Pain
OP-9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material
OP-11: Thorax CT – Use of Contrast Material
OP-12: The Ability for Providers with HIT to Receive
Laboratory Data Electronically Directly into their ONCCertified EHR System as Discrete Searchable Data
OP-13: Cardiac Imaging for Preoperative Risk Assessment for
Non Cardiac Low Risk Surgery
OP-14: Simultaneous Use of Brain Computed Tomography
(CT) and Sinus Computed Tomography (CT)
OP-15: Use of Brain Computed Tomography (CT) in the
Emergency Department for Atraumatic Headache

0286
0289
N/A
0528
0514
N/A
N/A
0513
N/A

0669
N/A
N/A

N/A
0496
N/A
0662
N/A
0661

N/A
N/A

OP-17: Tracking Clinical Results between Visits
OP-18: Median Time from ED Arrival to ED Departure for
Discharged ED Patients
OP-20: Door to Diagnostic Evaluation by a Qualified Medical
Professional
OP-21: Median Time to Pain Management for Long Bone
Fracture
OP-22: ED-Left Without Being Seen
OP-23: ED-Head CT or MRI Scan Results for Acute Ischemic
Stroke or Hemorrhagic Stroke who Received Head CT or MRI
Scan Interpretation Within 45 minutes of Arrival
OP-25: Safe Surgery Checklist Use
OP-26: Hospital Outpatient Volume on Selected Outpatient
Surgical Procedures

Data Collection
Mode
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Claims-based
Claims-based
Claims-based
Claims-based
Web-based

Claims-based
Claims-based
Claims-based
(deferred public
reporting)
Web-based
Chart-abstracted
Chart-abstracted
Chart-abstracted
Web-based
Claims-based

Web-based
Web-based

Chart-abstracted measures require the submission of patient-level information to be obtained
through chart abstraction that is then submitted electronically to CMS.
Claims-based measures are derived through analysis of administrative claims data and do not
require additional effort or burden on hospitals.
Web-based measures require hospitals to submit non-patient level data directly to CMS via the
CMS Web-based tool (QualityNet Website).

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Two (2) measures were removed (OP-19 and OP-24) and public reporting of one was deferred
(OP-15).
3. CY 2016 Payment Determination
CMS previously finalized in the CY 2013 OPPS/ASC final rule with comment period OP-27:
Influenza Vaccination Coverage among Healthcare Personnel, a Centers for Disease Control and
Prevention (CDC) measure. In the CY 2014 OPPS/ASC final rule with comment period, CMS
finalized that this data would be submitted via CDC’s Web-based tool located on the National
Healthcare Safety Network (NHSN) website.
In the CY 2014 OPPS/ASC final rule with comment period, CMS also adopted three (3) Webbased measures where numerator and denominator data are submitted directly to CMS via the
CMS Web-based tool (QualityNet Website).
On December 31, 2013, CMS issued guidance stating that we would delay the implementation of
OP-29, OP-30, and OP-31 by 3 months from January 1, 2014 to April 1, 2014 for the CY 2016
payment determination
(https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQ
netTier2&cid=1228721506778).
On April 2, 2014, CMS issued additional guidance stating that we would further delay the
implementation of OP-31 from April 1, 2014 to January 1, 2015 for the CY 2016 payment
determination
(https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQ
netTier2&cid=1228721506778).
In the CY 2015 OPPS/ASC final rule, we excluded OP-31 from the CY 2016 payment
determination measure set.
The entire measure set for the CY 2016 payment determination is outlined in the below table:
HOSPITAL OQR PROGRAM MEASURES FOR THE CY 2016 PAYMENT
DETERMINATION
NQF No.
N/A
0288
0290
0286
0289
N/A
0528
0514

Measure Name
OP-1: Median Time to Fibrinolysis
OP-2: Fibrinolytic Therapy Received Within 30 Minutes of
ED Arrival
OP-3: Median Time to Transfer to Another Facility for Acute
Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
OP-6: Timing of Antibiotic Prophylaxis
OP-7: Prophylactic Antibiotic Selection for Surgical Patients
OP-8: MRI Lumbar Spine for Low Back Pain
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Data Collection
Mode
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Claims-based

NQF No.

Measure Name

N/A
N/A
0513
N/A

OP-9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material
OP-11: Thorax CT – Use of Contrast Material
OP-12: The Ability for Providers with HIT to Receive
Laboratory Data Electronically Directly into their ONCCertified EHR System as Discrete Searchable Data
OP-13: Cardiac Imaging for Preoperative Risk Assessment for
Non Cardiac Low Risk Surgery
OP-14: Simultaneous Use of Brain Computed Tomography
(CT) and Sinus Computed Tomography (CT)
OP-15: Use of Brain Computed Tomography (CT) in the
Emergency Department for Atraumatic Headache

0669
N/A
N/A

N/A
0496
N/A
0662
N/A
0661

N/A
N/A
0431
0658

0659

OP-17: Tracking Clinical Results between Visits
OP-18: Median Time from ED Arrival to ED Departure for
Discharged ED Patients
OP-20: Door to Diagnostic Evaluation by a Qualified Medical
Professional
OP-21: Median Time to Pain Management for Long Bone
Fracture
OP-22: ED-Left Without Being Seen
OP-23: ED-Head CT or MRI Scan Results for Acute Ischemic
Stroke or Hemorrhagic Stroke who Received Head CT or MRI
Scan Interpretation Within 45 minutes of Arrival
OP-25: Safe Surgery Checklist Use
OP-26: Hospital Outpatient Volume on Selected Outpatient
Surgical Procedures
OP-27: Influenza Vaccination Coverage among Healthcare
Personnel
OP-29: Endoscopy/Poly Surveillance: Appropriate follow-up
interval for normal colonoscopy in average risk patients
OP-30: Endoscopy/Poly Surveillance: Colonoscopy interval
for Patients with a History of Adenomatous Polyps –
Avoidance of Inappropriate Use

Data Collection
Mode
Claims-based
Claims-based
Claims-based
Web-based

Claims-based
Claims-based
Claims-based
(deferred public
reporting)
Web-based
Chart-abstracted
Chart-abstracted
Chart-abstracted
Web-based
Claims-based

Web-based
Web-based
Web-based
Web-based
(deferred by 3
months)
Web-based
(deferred by 3
months)

4. CY 2017 Payment Determination
In the CY 2015 OPPS/ASC final rule with comment period, for the CY 2017 payment
determination, CMS removed two (2) measures from the Hospital OQR Program: OP-6: Timing
of Antibiotic Prophylaxis and OP-7: Prophylactic Antibiotic Selection for Surgical Patients
(NQF # 0528). CMS also finalized that reporting of OP-31: Cataracts – Improvement in
Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536) was

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voluntary, meaning that failure to report this measure would not affect a hospital’s payment
under the Hospital OQR Program.
In the CY 2016 OPPS/ASC proposed rule for the CY 2017 payment determination and
subsequent years, CMS is proposing to remove one (1) claims-based measure from the Hospital
OQR Program: OP-15: Use of Brain Computed Tomography (CT) in the Emergency Department
for Atraumatic Headache.
The entire measure set for the CY 2017 payment determination is outlined in the below table:
HOSPITAL OQR PROGRAM MEASURES FOR THE CY 2017 PAYMENT
DETERMINATION
NQF No.

Measure Name

N/A
0288

OP-1: Median Time to Fibrinolysis
OP-2: Fibrinolytic Therapy Received Within 30 Minutes of
ED Arrival
OP-3: Median Time to Transfer to Another Facility for Acute
Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
OP-8: MRI Lumbar Spine for Low Back Pain
OP-9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material
OP-11: Thorax CT – Use of Contrast Material
OP-12: The Ability for Providers with HIT to Receive
Laboratory Data Electronically Directly into their ONCCertified EHR System as Discrete Searchable Data
OP-13: Cardiac Imaging for Preoperative Risk Assessment for
Non Cardiac Low Risk Surgery
OP-14: Simultaneous Use of Brain Computed Tomography
(CT) and Sinus Computed Tomography (CT)
OP-15: Use of Brain Computed Tomography (CT) in the
Emergency Department for Atraumatic Headache

0290
0286
0289
0514
N/A
N/A
0513
N/A

0669
N/A
N/A

N/A
0496
N/A
0662
N/A
0661

OP-17: Tracking Clinical Results between Visits
OP-18: Median Time from ED Arrival to ED Departure for
Discharged ED Patients
OP-20: Door to Diagnostic Evaluation by a Qualified Medical
Professional
OP-21: Median Time to Pain Management for Long Bone
Fracture
OP-22: ED-Left Without Being Seen
OP-23: ED-Head CT or MRI Scan Results for Acute Ischemic
Stroke or Hemorrhagic Stroke who Received Head CT or MRI
6 of 19

Data Collection
Mode
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Claims-based
Claims-based
Claims-based
Claims-based
Web-based

Claims-based
Claims-based
Claims-based
(removal
proposed)
Web-based
Chart-abstracted
Chart-abstracted
Chart-abstracted
Web-based
Claims-based

NQF No.

Measure Name
Scan Interpretation Within 45 minutes of Arrival
OP-25: Safe Surgery Checklist Use
OP-26: Hospital Outpatient Volume on Selected Outpatient
Surgical Procedures
OP-27: Influenza Vaccination Coverage among Healthcare
Personnel
OP-29: Endoscopy/Poly Surveillance: Appropriate Follow-up
Interval for Normal Colonoscopy in Average Risk Patients
OP-30: Endoscopy/Poly Surveillance: Colonoscopy Interval
for Patients with a History of Adenomatous Polyps –
Avoidance of Inappropriate Use
OP-31 Cataracts – Improvement in Patient’s Visual Function
within 90 Days Following Cataract Surgery

N/A
N/A
0431
0658
0659

1536

Data Collection
Mode
Web-based
Web-based
Web-based
Web-based
Web-based

Web-based
(voluntary)

5. CY 2018 Payment Determination and Subsequent Years
In the CY 2015 OPPS/ASC final rule with comment period, for the CY 2018 payment
determination and subsequent years, we adopted one (1) claims-based quality measure, OP-32:
Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy (NQF
#2539).
In the CY 2016 OPPS/ASC proposed rule for the CY 2018 payment determination and
subsequent years, CMS is proposing to add one (1) Web-based quality measure, OP-33 External
Beam Radiotherapy for Bone Metastases (NQF #1822). We are proposing that hospitals can
either: 1) report aggregate level data for OP-33 via the CMS Web-based tool; or 2) submit an
aggregate data file for this measure through a vendor (via QualityNet infrastructure).
The entire measure set for the CY 2018 payment determination and subsequent years is outlined
in the below table:
PROPOSED HSOPITAL OQR PROGRAM MEASURE SET FOR THE CY 2018
PAYMENT DETERMINATION AND SUBSEQUENT YEARS
NQF No.

Measure Name

N/A
0288

OP-1: Median Time to Fibrinolysis
OP-2: Fibrinolytic Therapy Received Within 30 Minutes of
ED Arrival
OP-3: Median Time to Transfer to Another Facility for Acute
Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
OP-8: MRI Lumbar Spine for Low Back Pain
OP-9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material

0290
0286
0289
0514
N/A
N/A

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Data Collection
Mode
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Chart-abstracted
Claims-based
Claims-based
Claims-based

NQF No.

Measure Name

0513
N/A

OP-11: Thorax CT – Use of Contrast Material
OP-12: The Ability for Providers with HIT to Receive
Laboratory Data Electronically Directly into their ONCCertified EHR System as Discrete Searchable Data
OP-13: Cardiac Imaging for Preoperative Risk Assessment
for Non Cardiac Low Risk Surgery
OP-14: Simultaneous Use of Brain Computed Tomography
(CT) and Sinus Computed Tomography (CT)
OP-17: Tracking Clinical Results between Visits
OP-18: Median Time from ED Arrival to ED Departure for
Discharged ED Patients
OP-20: Door to Diagnostic Evaluation by a Qualified
Medical Professional
OP-21: Median Time to Pain Management for Long Bone
Fracture
OP-22: ED-Left Without Being Seen
OP-23: ED-Head CT or MRI Scan Results for Acute
Ischemic Stroke or Hemorrhagic Stroke who Received Head
CT or MRI Scan Interpretation Within 45 minutes of Arrival
OP-25: Safe Surgery Checklist Use
OP-26: Hospital Outpatient Volume on Selected Outpatient
Surgical Procedures
OP-27: Influenza Vaccination Coverage among Healthcare
Personnel
OP-29: Endoscopy/Poly Surveillance: Appropriate Follow-up
Interval for Normal Colonoscopy in Average Risk Patients
OP-30: Endoscopy/Poly Surveillance: Colonoscopy Interval
for Patients with a History of Adenomatous Polyps –
Avoidance of Inappropriate Use
OP-31 Cataracts – Improvement in Patient’s Visual Function
within 90 Days Following Cataract Surgery
OP-32: Facility 7-Day Risk-Standardized Hospital Visit Rate
after Outpatient Colonoscopy
OP-33: External Beam Radiotherapy for Bone Metastases

0669
N/A
N/A
0496
N/A
0662
N/A
0661

N/A
N/A
0431
0658
0659

1536
2539
1822

Data Collection
Mode
Claims-based
Web-based

Claims-based
Claims-based
Web-based
Chart-abstracted
Chart-abstracted
Chart-abstracted
Web-based
Claims-based

Web-based
Web-based
Web-based
Web-based
Web-based

Web-based
(voluntary)
Claims-based
Web-based
(proposed)

6. CY 2019 Payment Determination and Subsequent Years
In the CY 2016 OPPS/ASC proposed rule for the CY 2019 payment determination and
subsequent years, CMS is proposing to add one (1) Web-based quality measure, OP-34:
Emergency Department Transfer Communication Measure (NQF #0291). We are proposing that
hospitals can either: 1) report aggregate level data for OP-34 via the CMS Web-based tool; or 2)
submit an aggregate data file for this measure through a vendor (via QualityNet infrastructure).

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The entire measure set for the CY 2019 payment determination and subsequent years is outlined
in the below table:
PROPOSED HSOPITAL OQR PROGRAM MEASURE SET FOR THE CY 2019
PAYMENT DETERMINATION AND SUBSEQUENT YEARS
NQF No.

Measure Name

N/A
0288

OP- 1: Median Time to Fibrinolysis
OP- 2: Fibrinolytic Therapy Received Within 30 Minutes of
ED Arrival
OP- 3: Median Time to Transfer to Another Facility for
Acute
Coronary Intervention
OP- 4: Aspirin at Arrival
OP- 5: Median Time to ECG
OP- 8: MRI Lumbar Spine for Low Back Pain
OP- 9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material
OP-11: Thorax CT – Use of Contrast Material
OP-12: The Ability for Providers with HIT to Receive
Laboratory Data Electronically Directly into their ONCCertified EHR System as Discrete Searchable Data
OP-13: Cardiac Imaging for Preoperative Risk Assessment
for Non Cardiac Low Risk Surgery
OP-14: Simultaneous Use of Brain Computed Tomography
(CT) and Sinus Computed Tomography (CT)
OP-17: Tracking Clinical Results between Visits
OP-18: Median Time from ED Arrival to ED Departure for
Discharged ED Patients
OP-20: Door to Diagnostic Evaluation by a Qualified
Medical Professional
OP-21: Median Time to Pain Management for Long Bone
Fracture
OP-22: ED-Left Without Being Seen
OP-23: ED-Head CT or MRI Scan Results for Acute
Ischemic Stroke or Hemorrhagic Stroke who Received Head
CT or MRI Scan Interpretation Within 45 minutes of Arrival
OP-25: Safe Surgery Checklist Use
OP-26: Hospital Outpatient Volume on Selected Outpatient
Surgical Procedures
OP-27: Influenza Vaccination Coverage among Healthcare
Personnel
OP-29: Endoscopy/Poly Surveillance: Appropriate Follow-up
Interval for Normal Colonoscopy in Average Risk Patients
OP-30: Endoscopy/Poly Surveillance: Colonoscopy Interval

0290

0286
0289
0514
N/A
N/A
0513
N/A

0669
N/A
N/A
0496
N/A
0662
N/A
0661

N/A
N/A
0431
0658
0659

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Data Collection
Mode
Chart-abstracted
Chart-abstracted
Chart-abstracted

Chart-abstracted
Chart-abstracted
Claims-based
Claims-based
Claims-based
Claims-based
Web-based

Claims-based
Claims-based
Web-based
Chart-abstracted
Chart-abstracted
Chart-abstracted
Web-based
Claims-based

Web-based
Web-based
Web-based
Web-based
Web-based

NQF No.

1536
2539
1822
0291

Measure Name
for Patients with a History of Adenomatous Polyps –
Avoidance of Inappropriate Use
OP-31 Cataracts – Improvement in Patient’s Visual Function
within 90 Days Following Cataract Surgery
OP-32: Facility 7-Day Risk-Standardized Hospital Visit Rate
after Outpatient Colonoscopy
OP-33: External Beam Radiotherapy for Bone Metastases
OP-34: Emergency Department Transfer Communication
Measure

Data Collection
Mode

Web-based
(voluntary)
Claims-based
Web-based
(proposed)
Web-based
(proposed)

7. Forms Used in Hospital OQR Program Procedures
To administer the Hospital OQR Program, several forms are utilized: Notice of Participation,
Extraordinary Circumstances Extensions/Exemptions Request, and Reconsideration Request.
None of these forms is completed on an annual basis; all are on a need to use, exception basis
and most hospitals will not need to complete any of these forms in any given year.
To begin participation in the Hospital OQR Program, all subsection (d) hospitals reimbursed
under the OPPS must complete a Notice of Participation. This form explains the participation
and reporting requirements of the program, and can be submitted electronically through on-line
completion, by mailing, or via fax. The form explains that to receive the full annual payment
update, the hospital acknowledges that data submitted under the program can be made publicly
available. Hospitals that are not subsection (d) or are not reimbursed under the OPPS may
voluntarily participate in the program; these hospitals have the option to submit data with or
without public release of the information. Hospitals that want to withdraw from participation or
those who do not want their data made publicly available may withdraw from participation using
the same Notice of Participation form. This form can be found on the QualityNet website. Once
this form is submitted for a hospital, it remains in effect. A hospital would need to resubmit this
form only if it has withdrawn and wants to renew participation. In the CY 2016 proposed rule,
CMS is proposing that beginning with the CY 2017 payment determination, hospitals must
submit a withdrawal form no later than August 31 of the year prior to the affected annual
payment update.
In the event of extraordinary circumstances not within the control of the hospital, such as a
natural disaster, a hospital can request an exemption or extension for meeting program
requirements. For the hospital to receive consideration for an extension or exemption, an
Extraordinary Circumstances Extensions/Exemptions Request must be submitted. This form can
be found on-line and can be submitted electronically, by mail, or fax.
When CMS determines that a hospital has not met program requirements and has had a 2
percentage point reduction in their APU, the hospital may submit a request for reconsideration.
This request must be submitted to CMS by the first business day in February in the year the
payment reduction has occurred. In the CY 2016 proposed rule, CMS is proposing that beginning
with the CY 2018 payment determination, hospitals must submit a reconsideration request to
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CMS no later than the first business day on or after March 17 of the affected payment year. This
form can be found on the QualityNet website; it can be submitted via Secure File Transfer using
the QualityNet Secure Portal or via secure fax.
C.

Justification

1. Need and Legal Basis
Section 109(a) of the Tax Relief and Health Care Act of 2006 (TRHCA) (Pub. L. 109-432)
amended section 1833(t) of the Social Security Act by adding a new subsection (17) that affects
the payment rate update applicable to OPPS payments for services furnished by hospitals in
outpatient settings on or after January 1, 2009. Section 1833(t)(17)(A) of the Act, which applies
to hospitals as defined under section 1886(d)(1)(B) of the Act, requires that hospitals that fail to
report data required for quality measures selected by the Secretary in the form and manner
required by the Secretary under section 1833(t)(17)(B) of the Act will incur a reduction in their
annual payment update factor to the hospital outpatient department fee schedule by 2.0
percentage points. Sections 1833(t)(17)(C)(i) and (ii) of the Act require the Secretary to develop
measures appropriate for the measurement of the quality of care furnished by hospitals in
outpatient settings.
Continued expansion of the quality measure set is consistent with the letter and spirit of the
authorizing legislation, TRCHA, to collect and make publicly available hospital-reported
information on the quality of care delivered in the hospital outpatient setting and to utilize a
formal consensus process as defined under the ACA. As reflected by claims-based quality
measures, Web-based quality measures, and the NHSN measure, efforts are made to reduce
burden by limiting the adoption of measures requiring the submission of patient-level
information that must be acquired through chart abstraction and to employ existing data and data
collection systems.
2. Information Users
CMS uses this information to direct its contractors to focus on particular areas of improvement
and to develop quality improvement initiatives. The information is made available to hospitals
for their use in internal quality improvement initiatives. Most importantly, this information is
available to Medicare beneficiaries, as well as to the general public, to provide hospital
information to assist them in making decisions about their health care.
3. Improved Information Technology
To assist hospitals in this initiative, CMS employs the use of an established, free data collection
tool, the CMS Abstraction and Reporting Tool (CART). In addition, CMS provides a secure
data warehouse and use of the QualityNet website for storage and transmittal of data as well as
data validation and aggregation services prior to the release of data to the CMS website.
Hospitals also have the option of using vendors to transmit the data. CMS has engaged a
national support contractor to provide technical assistance with the data collection tool, other
program requirements, and to provide education.

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For the claims-based measures, this section is not applicable as claims-based measures are
calculated from administrative claims data that result from claims submitted by hospitals to
Medicare for reimbursement. Therefore, no additional information technology will be required
for hospitals for these measures.
4. Duplication of Similar Information
The information to be collected is not duplicative of similar information collected by CMS or
other efforts to collect quality of care data for outpatient hospital care. As required by statute,
CMS requires hospitals to submit quality measure data for services provided in the outpatient
setting.
Hospitals are required to complete and submit a written form on which they agree to participate
in the Hospital OQR Program. This declaration remains in effect, even as the measure set
changes, until such time as a hospital specifically elects to withdraw.
5. Small Business
Information collection requirements are designed to allow maximum flexibility specifically to
small hospitals wishing to participate in hospital reporting. This effort will assist small hospitals
in gathering information for their own quality improvement efforts.
6. Less Frequent Collection
CMS has designed the collection of quality of care data to be the minimum necessary for data
validation and calculation of summary figures to be reliable estimates of hospital performance.
To collect the information less frequently would compromise the timeliness of any calculated
estimates.
7. Special Circumstances
All subsection (d) hospitals reimbursed under the OPPS must meet Hospital OQR Program
Requirements, including administrative, data submission, and validation requirements to receive
the full OPPS payment update for the given calendar year. Failure to meet all requirements may
result in a 2.0 percentage point reduction in the APU.
8. Federal Register Notice/Outside Consultation
The 60-day Federal Register notice for this data collection is scheduled to be published on
November 1, 2015. The CY 2016 OPPS/ASC proposed rule with comment period can be found
on the Federal Register and CMS websites. Comments are currently being submitted on this
notice and CMS will respond to those comments accordingly.
CMS is supported in this program’s efforts by The Joint Commission, NQF, MAP, and CDC.
These organizations collaborate with CMS on an ongoing basis, providing technical assistance in
developing and identifying quality measures, and assisting in making collected information
accessible, understandable, and relevant.

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9. Payment/Gift to Respondent
Hospitals are required to submit this data in order to receive the full OPPS payment update. No
other payments or gifts will be given to respondents for participation.
10. Confidentiality
All information collected under the Hospital OQR Program will be maintained in strict
accordance with statutes and regulations governing confidentiality requirements for CMS data.
In addition, the tools used for transmission and storage of data are considered confidential forms
of communication and are HIPAA compliant.
11. Sensitive Questions
Case specific clinical data elements will be collected and are necessary to calculate statistical
measures. These statistical measures are the basis of subsequent improvement activities and
cannot be calculated without the case specific data. Case specific data will not be released to the
public and are not releasable by requests under the Freedom of Information Act. Only hospitalspecific data will be made publicly available as mandated by statute. In addition, the tools used
for transmission of data are considered confidential forms of communication and are HIPAA
compliant.
12. Burden Estimate (Total Hours & Wages)
Section 109(a) of the Tax Relief and Health Care Act of 2006 (TRCHA) (Pub. L. 109-432)
establishes requirements that affect the payment rate update applicable to OPPS payments for
services furnished by hospitals in outpatient settings on or after January 1, 2009. Section
1833(t)(17)(A) of the Act, which applies to hospitals as defined under section 1886(d)(1)(B) of
the Act, requires that hospitals that fail to report data required for quality measures selected by
the Secretary in the form and manner required by the Secretary under section 1833(t)(17)(B) of
the Act will incur a reduction in their annual payment update factor to the hospital outpatient
department fee schedule by 2.0 percentage points. Sections 1833(t)(17)(C)(i) and (ii) of the Act
require the Secretary to develop measures appropriate for the measurement of the quality of care
furnished by hospitals in outpatient settings. The program established under these amendments is
referred to as the Hospital OQR Program.
CY 2015
For the CY 2015 payment determination, the burden associated with program requirements is the
time and effort associated with collecting and submitting the data on the required measures, and
submitting documentation for validation purposes. CMS estimated that there would be
approximately 3,200 respondents per year. For hospitals to collect and submit the information on
the chart-abstracted measures, CMS estimated it would take 35 minutes to abstract all measures
per sampled case. Based upon the data submitted for the CY 2011 and 2012 payment
determinations, CMS estimated there would be a total of 1,628,800 cases per year,
approximately 509 cases per respondent. The estimated annual burden associated with the
submission requirements for these chart-abstracted measures is 949,590 hours (1,628,800 cases
per year × 0.583 hours per case). In addition, hospitals would incur a financial burden associated
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with chart abstraction and data submission where patient level data is submitted directly to CMS.
Estimating that hospitals would pay $30 per hour for chart abstraction and data submission, we
estimated the financial burden associated with these measures is $28,487,712 (1,628,800 cases
per year × $30.00 per hour × 0.583 hours per case).
For the five (5) Web-based measures, CMS estimated that each participating hospital would
spend 10 minutes per year to collect and submit the required data, making the estimated annual
burden associated with these measures 2,672 hours (3,200 hospitals × 0.167 hours per measure ×
5 measures per hospital). In addition, hospitals would incur a financial burden associated with
data collection and data submission for these 5 measures. CMS estimated that the financial
burden associated with these measures would be $16,032 (3,200 hospitals × $30.00 per hour ×
0.167 hours per measure × 5 measures).
For validation of hospital self-reported data, a random sample of 450 participating hospitals is
selected plus up to 50 additional hospitals based upon targeting criteria; a total of up to 500
hospitals. For each selected hospital, up to 48 patient encounters will be selected from the total
number of cases that the hospital successfully submitted to CMS. The burden associated with the
CY 2015requirement is the time and effort necessary to submit supporting medical record
documentation. CMS estimated that it would take each of the selected hospitals approximately
12 hours to comply with these information request requirements. To comply with the
requirements, CMS estimated each hospital must submit up to 48 cases for the affected year for
review. All selected hospitals must comply with these requirements each year, which would
result in a total of up to 24,000 charts being submitted by the sampled hospitals. The estimated
annual hourly burden associated with the data validation process for CY 2015 payment
determinations is approximately 6,000 hours. In addition, hospitals would incur a financial
burden associated with the required information submission requirement. CMS estimated that the
financial burden associated with this would be $180,000 ($30.00 per hour × 6,000 hours).
CY 2016
For the CY 2016 payment determination, the burden associated with program requirements is the
time and effort associated with completing, collecting, and submitting the data on the required
measures, and submitting documentation for validation purposes. CMS estimated that there
would be approximately 3,300 respondents per year. For hospitals to collect and submit chartabstracted measures where patient-level data is submitted directly to CMS, we estimated it would
take 35 minutes to abstract all measures per submitted case. Based upon the data submitted for
the CY 2012 and CY 2013 payment determinations, CMS estimated there would be a total of
1,679,700 cases per year, approximately 509 cases per year per hospital. Therefore, the estimated
annual hourly burden associated with the aforementioned data submission requirements is
979,265 hours (1,679,700 cases per year × 0.583 hours per case). In addition, hospitals would
incur a financial burden associated with chart abstraction and data submission where patient
level data is submitted directly to CMS. Estimating that hospitals would pay $30 per hour for
chart abstraction and data submission, we estimated the financial burden associated with these
measures is $29,377,953 (1,679,700 cases per year × $30.00 per hour × 0.583 hours per case).
For the measures where data is submitted to CMS via a Web-based, on-line tool located on a
CMS website, we estimated that each participating hospital would spend 10 minutes per year to
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collect and submit the data, making the estimated annual burden associated with these measures
4,960 hours (3,300 hospitals × 0.167 hours per measure × 9 measures per hospital) in CY 2015.
In addition, hospitals would incur a financial burden associated with data collection and data
submission for these 9 measures. CMS estimated that the financial burden associated with these
measures would be $148,797 (3,300 hospitals × $30.00 per hour × 0.167 hours per measure × 9
measures).
For the NHSN HAI measure: Influenza Vaccination Coverage among Healthcare Personnel,
CMS estimated that the total annual burden associated with this measure for a hospital for data
submission would be 27,555 hours (3,300 hospitals × 0.167 hours per measure × 50 workers per
hospital). In addition, hospitals would incur a financial burden associated with data submission
for this measure. CMS estimated that the financial burden associated with this measure is
$826,650 ($30.00 per hour × 27,555 hours).
The burden associated with the validation procedures for the CY 2016 payment determination is
the same as for CY 2015 payment determination and is the time and effort necessary to submit
supporting medical record documentation for validation. CMS estimated that it would take each
of the sampled hospitals approximately 12 hours to comply with these data submission
requirements. To comply with the requirements, CMS estimated each hospital would submit up
to 48 cases for the affected year for review. All selected hospitals must comply with these
requirements each year, which would result in a total of up to 24,000 charts being submitted by
the selected hospitals (500 hospitals × 48 cases per hospital). The estimated annual burden
associated with the data validation process for the CY 2015 payment determination is
approximately 6,000 hours. In addition, hospitals would incur a financial burden associated with
the required information submission requirement. CMS estimated that the financial burden
associated with this measure is $180,000 ($30.00 per hour × 6,000 hours).
CY 2017
For the CY 2017 payment determination, the burden associated with program requirements is the
time and effort associated with collecting and submitting the data on the required measures, and
submitting documentation for validation purposes. CMS estimated that there would be
approximately 3,300 respondents per year. CMS estimated that the burden associated with these
requirements was 42 hours per hospital or 138,600 hours for all hospitals. CMS estimated the
financial burden for these requirements would be $4.2 million ($30/hour x 138,600) for all
hospitals.
With regard to chart-abstracted measures where patient-level data is submitted directly to CMS,
in the CY 2015 OPPS/ASC final rule with comment period, CMS removed OP-6 and OP-7 from
the Hospital OQR Program for the CY 2017 payment determination and subsequent years. CMS
previously estimated that each participating hospital would spend 35 minutes (or 0.583 hours)
per case for 12 chart-abstracted measures (OP-1, OP-2, OP-3, OP-4, OP-5, OP-6, OP-7, OP-18,
OP-20, OP-21, OP-22, OP-23). Since CMS removed two of these measures, we believed that the
time to chart-abstract measures would be reduced by 16.7 percent (2 of 12 measures). Therefore,
CMS estimated that hospitals would spend approximately 29 minutes (0.483 hours) per case, or
2.9 minutes per measure, to collect and submit the data for these 10 measures. Based upon the
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data submitted for the CY 2014 payment determination, hospitals would submit approximately
1,266 cases per year for these measures. Therefore, CMS estimated that the time it would take a
hospital to abstract data for all of the chart-abstracted measures would be 612 hours per year
(1,266 cases x 0.483 hours), resulting in a burden of 2.02 million hours (612 hours x 3,300
hospitals) for all participating hospitals, for a total financial burden of approximately $61 million
(2.02 million hours x $30/hour). In addition, CMS estimated that OP-29 and OP-30 would
require 25 minutes (0.417 hours) per case per measure to chart-abstract. CMS estimated that
hospitals would abstract 384 cases per year for each of these measures. Therefore, for the
CY 2017 payment determination and subsequent years, we estimated a burden of 1.1 million
hours (3,300 hospitals x 0.417 hours/case x 384 case/measure x 2 measures) for all participating
hospitals for OP-29 and OP-30 for a total financial burden of approximately $33 million
($30/hour x 1.1 million hours). CMS estimated that OP-31 would require 25 minutes (0.417
hours) per case to chart-abstract. CMS also estimated that hospitals would abstract 384 cases per
year for this measure. CMS estimated that approximately 20 percent of hospitals (660 hospitals
(3,300 hospitals x 0.2)) would elect to report this measure on a voluntary basis. Therefore, we
estimated that the burden for this measure would be 105,685 hours (660 hospitals x 0.417
hours/case x 384 cases) for participating hospitals for the CY 2017 payment determination and
subsequent years, for a total financial burden of approximately $3.2 million ($30/hour x 105,685
hours). Thus, for chart-abstracted measures, CMS estimated a total burden for all participating
hospitals of 3.23 million hours (2.02 million hours + 105,685 hours + 1.1 million hours) and
$96.9 million (3.23 million hours x $30/hour) for the CY 2017 payment determination and
subsequent years.
With regard to measures for which data is submitted via the Web-based tool, CMS estimated that
each participating hospital would spend 10 minutes per measure per year to collect and submit
the data for the six measures (OP-12, OP-17, OP-25, OP-26, OP-29, and OP-30). Therefore, the
estimated annual burden associated with these measures for all participating hospitals is 3,307
hours (3,300 hospitals x 0.167 hours/measure x 6 measures/hospital) for the CY 2017 payment
determination and subsequent years. As discussed above, in the CY 2015 final rule, CMS made
reporting for OP-31 voluntary. We estimated that approximately 20 percent of hospitals (660
hospitals (3,300 hospitals x 0.2)) would elect to report OP-31 on a voluntary basis. Therefore,
CMS estimated that the burden for this measure for all participating hospitals would be 111
hours (660 hospitals x 0.167 hours) for the CY 2017 payment determination and subsequent
years. Thus, CMS estimated that the financial burden incurred for the web-based submission of
these measures for all participating hospitals would be $119,070 ($30/hour x (3,858 hours + 111
hours) for the CY 2017 payment determination and subsequent years.
CMS estimated a total burden for all participating hospitals of 106,940 hours and a total financial
burden of $3,208,200 associated with the NHSN HAI measure (OP-27) for the CY 2017
payment determination and subsequent years.
For prior payment determinations, CMS sampled 500 hospitals for validation and estimated that
it would take each hospital 12 hours to comply with the data submission requirements for four
quarters. For the CY 2017 payment determination, CMS is proposing transitioning to a new
payment determination timeframe; as a result only three quarters of data will be used for
determining the CY 2017 payment determination. Therefore, CMS estimates that data
submission for three quarters would reduce the number of hours required by 25 percent (from 12
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hours to 9 hours per hospital.) CMS estimates a total burden of approximately 4,500 hours (500
hospitals x 9 hours/hospital) and a total financial impact of $135,000 ($30/hour x 4,500 hours)
for the CY 2017 payment determination and subsequent years
CY 2018
For the CY 2018 payment determination, the burden associated with program requirements is the
time and effort associated with collecting and submitting the data on the required measures, and
submitting documentation for validation purposes. CMS estimated that there would be
approximately 3,300 respondents per year. Below, we discuss only the incremental burden
associated with the proposals made for the CY 2018 payment determination and subsequent
years. We have not included the burden discussed in the sections above that continue for future
years.
For the CY 2018 payment determination and subsequent years, the Hospital OQR program
returns to its four-quarter payment determination cycle. The burden associated with the
validation procedures is the time and effort necessary to submit supporting medical record
documentation for validation. CMS estimates that it will take each of the sampled hospitals
approximately 12 hours to comply with these data submission requirements. To comply with the
requirements, CMS estimates each hospital would submit up to 48 cases for the affected year for
review. All selected hospitals must comply with these requirements each year, which would
result in a total of up to 24,000 charts being submitted by the selected hospitals (500 hospitals ×
48 cases per hospital). The estimated annual burden associated with the data validation process
for the CY 2018 payment determination is approximately 6,000 hours. In addition, hospitals
would incur a financial burden associated with the required information submission requirement.
CMS estimated that the financial burden associated with this measure is $180,000 ($30.00 per
hour × 6,000 hours).
For the CY 2018 payment determination and subsequent years, CMS is proposing one new
measure: OP-33: External Beam Radiotherapy (EBRT) for Bone Metastases (NQF # 1822).
CMS is proposing that hospitals can either: 1) report aggregate level data for OP-33 via the CMS
Web-based tool; or 2) submit an aggregate data file for this measure through a vendor (via
QualityNet infrastructure). For hospitals choosing the first method, CMS previously estimated
that it would take hospitals approximately 2.92 minutes (or 0.049 hours) per case to collect chartabstracted data for a single Web-based measure. Based on our most recent data (Quarter 4 2013
– Quarter 3 2014) for Hospital OQR Program measures, CMS estimates that the average hospital
will submit 48 cases per year for the EBRT measure. Therefore, CMS believes that the average
hospital will spend 2.352 hours (0.049 hours/measure/case x 48 cases) chart-abstracting data for
this measure. In addition, consistent with prior years, CMS estimated that each participating
hospital will spend 10 minutes (0.167 hours) per measure per year to collect and submit the data
via the Web-based tool. Therefore, CMS estimates that, in total, the proposed measure will
increase burden by 2.519 hours (2.352 hours + 0.167 hours) per year. As stated above,
approximately 3,300 hospitals participate in the Hospital OQR Program. Therefore, CMS
estimates a total increase in burden across all participating hospitals of 8,312.7 hours (2.519
hours/hospital x 3,300 hospitals) per year associated with this measure. Finally, consistent with
prior years, we estimate that a hospital pays an individual approximately $30 per hour to abstract
and submit these data. Therefore, we estimate a total financial increase in burden to be $75.57
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per hospital (2.519 hours x $30/hour) or $249,000 (8,312.7 hours x $30/hour) across all
participating hospitals as a result of our proposals for the CY 2018 payment determination and
subsequent years. For hospitals choosing the second data submission method, because CMS does
not have any baseline data on which to estimate how many hospitals might elect to submit data
through a vendor, we will assume for the first year that all participating hospitals will incur the
burden of submitting data through the Web-based tool. In future years, CMS will adjust the
burden estimate to account for hospitals that elect to submit data through a vendor.
CY 2019
For the CY 2019 payment determination, the burden associated with program requirements is the
time and effort associated with collecting and submitting the data on the required measures, and
submitting documentation for validation purposes. CMS estimated that there would be
approximately 3,300 respondents per year. Below, we discuss only the incremental burden
associated with the proposals made for the CY 2019 payment determination and subsequent
years. We have not included the burden discussed in the sections above that continue for future
years.
For the CY 2019 payment determination and subsequent years, CMS is proposing one new
measure: OP-34: Emergency Department Transfer Communication (EDTC) (NQF # 0291).
CMS proposed that hospitals can either: 1) report aggregate level data for OP-34 via the CMS
Web-based tool; or 2) submit an aggregate data file for this measure through a vendor (via
QualityNet infrastructure). For hospitals choosing the first method, CMS previously estimated
that it would take hospitals approximately 2.92 minutes (or 0.049 hours) per case to collect chartabstracted data for a single Web-based measure. Based on our most recent data (Quarter 4 2013
– Quarter 3 2014) for OQR ED-Throughput measures, CMS estimates that the average hospital
will submit 495 cases per year for EDTC. Therefore, CMS believes that the average hospital
will spend 24.255 hours (0.049 hours/case x 495 cases) chart-abstracting data for this measure.
In addition, CMS estimates that each participating hospital would spend 10 minutes (0.167
hours) per measure per year to collect and submit the data via the Web-based tool. Therefore,
CMS estimates that, in total, the proposed measure would increase burden by 24.422 hours
(24.255 hours + 0.167 hours) per year. Approximately 3,300 hospitals participate in the Hospital
OQR Program. Therefore, we estimate a total financial increase in burden to be $732.66 per
hospital (24.422 hours x $30/hour) or $2.418 million (80,592.6 hours x $30/hour) across all
participating hospitals as a result of our proposals for the CY 2019 payment determination and
subsequent years. For hospitals choosing the second data submission method, because CMS does
not have any baseline data on which to estimate how many hospitals might elect to submit data
through a vendor, we will assume for the first year that all participating hospitals will incur the
burden of submitting data through the Web-based tool. In future years, CMS will adjust the
burden estimate to account for hospitals that elect to submit data through a vendor.
Accordingly, we estimate the total annual financial burden for reporting all measure data for CY
2016 to be $30,533,400. We estimate the total annual financial burden for reporting all measure
data for CY 2017 to be $104,562,270. We estimate the total annual financial burden for
reporting all measure data for CY 2018 to be $104,856,270. Therefore, the average annual
financial burden for CY 2016, CY 2017, and CY 2018 is approximately $80 million.

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13. Capital Costs (Maintenance of Capital Costs)
There are no capital costs being placed on the hospitals. In fact, successful submission will
result in a hospital receiving the full payment update, while having to expend no capital costs for
participation. CMS is providing a data collection tool and method for submission of data to the
participants. There are no additional data submission requirements placing additional cost
burdens on hospitals.
14. Cost to Federal Government
The cost to the Federal Government is approximately $11,500,000 on an annual basis. CMS
must maintain and update existing information technology infrastructure on QualityNet and the
CART tool. CMS must also provide ongoing technical assistance to hospitals and data vendors
to participate in the program. CMS also calculates four additional claims-based imaging
efficiency measures for hospital outpatient departments, and provide hospitals with feedback
reports about all of the measures.
Hospitals report outpatient quality data directly to CMS through the CART or QualityNet as they
already do for inpatient quality data. Tools will be revised as needed and updates will be
incorporated.
15. Program or Burden Changes
The program has increased the number of measures included in its data collection requirements.
Therefore, there is a net increase in burden.
16. Publication or Burden Changes
The goal of the data collection is to tabulate and publish hospital specific data. CMS will
continue to display information on the quality of care provided in the hospital outpatient setting
for public viewing as by TRHCA. Data from this initiative is currently used to populate the
Hospital Compare Web site, www.hospitalcompare.hhs.gov.
17. Expiration Date
We request a 10/31/2017 expiration date as Hospital OQR Program requirements and activities
outlined are included to this date in this request.
18. Certification Statement
We certify that the Hospital OQR Program complies with 5 CFR 1320.9.

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