Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201609-0938-002 · OMB 0938-1022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction
CMS-10210 Data Accuracy and Completeness Form IQR_DACA__PY 2018_vFinal_9.2.2016.doc	Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form HVBP_Review_and_Corrections_Request_Form_Final_9.2.2016.doc	Form and Instruction
CMS-10210 Extraordinary Circumstances Form ECE Request Form Final 9.2.2016.docx	Form and Instruction
CMS-10210 Inpatient Withholding Data form PR_Oct2016_IP_HCWithholdingRequestForm9.2.2016.doc	Form and Instruction
CMS-10210 IQR Measure Exception Form IPPS_MeasureExceptionForm_9.2.2016.docx	Form and Instruction
CMS-10210 IQR Notice of Participation Form IQR NOP Text 9.2.2016.docx	Form and Instruction
CMS-10210 IQR Reconsideration Request Form QR_Form_APUReconsiderationRequest_9.2.2016_Final.docx	Form and Instruction
CMS-10210 CAUTI Validation Template FY18_CAUTI_ValTemp_9.2.2016.xlsx	Form and Instruction
CMS-10210 CDI Validation Template FY18_CDI_ValTemp_9.2.2016.xlsx	Form and Instruction
CMS-10210 CLABSI Validation Template FY18_CLABSI_ValTmplt_9.2.2016.xlsx	Form and Instruction
CMS-10210 MRSA Validation Template FY18_MRSA_ValTemp_9.2.2016.xlsx	Form and Instruction
CMS-10210 Validation Review for Reconsideration Request IQR_Form_ValidnReviewReq_9.2.2016_Final.docx	Form and Instruction
CMS-10210 VBP Appeal Request Form HVBP Appeal Request Form Final 9.2.2016.docx	Form and Instruction
CMS-10210 HVBP CMS Independent Review Form HVBP CMS Independent Review Form_9.2.2016_Final.doc	Form and Instruction
FY 2017 IPPS Final Rule Summary of HIQR PRA Information Collection Forms.docx Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Quality Measures and Procedures for Hospital Reporting of Quality Data

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10210	Data Accuracy and Completeness Form	IQR_DACA__PY 2018_vFinal_9.2.2016.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital VPB Review and Corrections Form	HVBP_Review_and_Corrections_Request_Form_Final_9.2.2016.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Extraordinary Circumstances Form	ECE Request Form Final 9.2.2016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Inpatient Withholding Data form	PR_Oct2016_IP_HCWithholdingRequestForm9.2.2016.doc	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Measure Exception Form	IPPS_MeasureExceptionForm_9.2.2016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Notice of Participation Form	IQR NOP Text 9.2.2016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Reconsideration Request Form	QR_Form_APUReconsiderationRequest_9.2.2016_Final.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	CAUTI Validation Template	FY18_CAUTI_ValTemp_9.2.2016.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	CDI Validation Template	FY18_CDI_ValTemp_9.2.2016.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	CLABSI Validation Template	FY18_CLABSI_ValTmplt_9.2.2016.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	MRSA Validation Template	FY18_MRSA_ValTemp_9.2.2016.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Review for Reconsideration Request	IQR_Form_ValidnReviewReq_9.2.2016_Final.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	VBP Appeal Request Form	HVBP Appeal Request Form Final 9.2.2016.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP CMS Independent Review Form	HVBP CMS Independent Review Form_9.2.2016_Final.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,400

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,600	0	17,600
Annual IC Time Burden (Hours)	3,681,023	-4,270,672	7,951,695
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk	FY 2017 IPPS Final Rule Summary of HIQR PRA Information Collection Forms.docx	09/12/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.