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.

This Measure Exception Form may be used for the following measures: Perinatal Care (PC-01), Emergency Department (ED-1 and ED-2), and Healthcare-Associated Infection [Surgical Site Infection (SSI), Catheter-Associated Urinary Tract Infection (CAUTI), Central Line-Associated Bloodstream Infection (CLABSI)]. This form may be used by the following programs: Hospital Inpatient Quality Reporting (IQR), Hospital Value-Based Purchasing (VBP), and Hospital-Acquired Condition (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)

 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  April 1 through June 30

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

 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  April 1 through June 30

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

Specified Colon and Abdominal Hysterectomy Surgical Procedures

 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) _______

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.

Specified CAUTI and CLABSI Requirements

As of January 1, 2015, acute care hospitals are required to report CLABSI and CAUTI data from all patient care locations that are mapped as National Healthcare Safety Network (NHSN) adult and pediatric medical, surgical, and medical/surgical wards, in addition to the ongoing reporting from Intensive Care Units (ICU). The requirement to report from ward locations will be limited to those locations that are mapped as/defined as Centers for Disease Control and Prevention (CDC) adult and pediatric medical, surgical, and medical/surgical wards, as provided below:

CDC Location Label	CDC Location Code
Medical Ward	IN:ACUTE:WARD:M
Medical/Surgical Ward	IN:ACUTE:WARD:MS
Surgical Ward	IN:ACUTE:WARD:S
Pediatric Medical Ward	IN:ACUTE:WARD:M_PED
Pediatric Medical/Surgical Ward	IN:ACUTE:WARD:MS_PED
Pediatric Surgical Ward	IN:ACUTE:WARD:S_P

 Central Line-Associated Bloodstream Infection (CLABSI)

Hospital has no ICU locations or Adult or Pediatric Medical, Surgical, or Medical/Surgical wards.

Calendar Year (YYYY) ____________

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

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

 Catheter-Associated Urinary Tract Infection (CAUTI)

Hospital has no ICU locations or Adult or Pediatric Medical, Surgical, or Medical/Surgical wards.

Calendar Year (YYYY) ____________

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

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

Any unit that meets the definition of – and is mapped as – a specific type that is not an ICU, Neonatal ICU, or one of the six wards listed above (e.g., mapped as orthopedic ward, telemetry ward, step-down unit) will not be required for CMS IPPS reporting in 2016 and forward; any data reported from non-required units in NHSN will not be submitted to CMS.

*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, and/or CAUTI measures, as indicated on this form.

*Name: _____________________________________________________________________

*Position: ___________________________________________________________________

Submission Instructions

Complete and submit this form via email to [email protected], secure fax to 877-789-4443, or QualityNet Secure Portal, Secure File Transfer “Waiver Exception Withholding” group.

Following receipt of this request form, CMS will provide an email acknowledgement that the request has been received.

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 0938-1022.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.

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 0938-1022.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.

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 0938-1022.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.

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 0938-1022.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.

Expiration Date: xx-xx-xxxx

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