(CMS-10210) Hospital Reporting Initiative--Hospital Quality Measures

Forms and Documents

Document Name	Status
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Modified
CMS-10210 FY 2018 HIQR Supporting Statement A 3-23-17.docx Supporting Statement A	2017-05-08

IC Document Collections

IC ID	Document Title	Status
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 201705-0938-004
Status: Historical Inactive	Previous ICR Reference No: 201609-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 21471
Title: (CMS-10210) Hospital Reporting Initiative--Hospital Quality Measures
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 07/27/2017
	Date Received in OIRA: 05/19/2017
Terms of Clearance: OMB files this comment in accordance with 5 CFR 1320.11( c ). This OMB action is not an approval to conduct or sponsor an information collection under the Paperwork Reduction Act of 1995. This action has no effect on any current approvals. If OMB has assigned this ICR a new OMB Control Number, the OMB Control Number will not appear in the active inventory. For future submissions of this information collection, reference the OMB Control Number provided. OMB is withholding approval at this time. Prior to publication of the final rule, the agency should provide a summary of any comments related to the information collection and their response, including any changes made to the ICR as a result of comments. In addition, the agency must enter the correct burden estimates.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2020
Responses	17,600	0	17,600
Time Burden (Hours)	3,681,023	0	3,681,023
Cost Burden (Dollars)	0	0	0

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Abstract: In the FY 2018 IPPS/LTCH PPS proposed rule, we are proposing to pilot the Hybrid Hospital-Wide 30-Day Readmission measure on a voluntary basis. We also are proposing to modify our previously finalized electronic clinical quality measure (eCQMs) reporting requirements for the FY 2019 payment determination such that hospitals would be required to report on six eCQMs and to submit two, self-selected, calendar quarters of data. Additionally, we are proposing to modify the eCQM reporting requirements for the FY 2020 payment determination, such that hospitals would be required to report on six eCQMs and to submit data for the first three calendar quarters (Q1-Q3) of CY 2018. Lastly, we are proposing to modify our existing eCQM validation process for the Hospital IQR Program data beginning with the FY 2020 payment determination. Specifically, we are proposing to require 8 cases to be submitted per quarter for 2 quarters for eCQM validation for the FY 2020 payment determination and 8 cases to be submitted per quarter for 3 quarters for eCQM validation for the FY 2021 payment determination.

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Authorizing Statute(s): PL: Pub.L. 108 - 173 5001(b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   PL: Pub.L. 111 - 148 3001 Name of Law: Affordable Care Act
   PL: Pub.L. 109 - 171 5001(a) Name of Law: Hospital Quality Improvement
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS98	Proposed rulemaking	82 FR 19796	04/28/2017

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Quality Measures and Procedures for Hospital Reporting of Quality Data	CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210	Data Accuracy and Completeness Form ,   Hospital VPB Review and Corrections Form ,   Extraordinary Circumstances Form ,   Inpatient Withholding Data form ,   IQR Measure Exception Form ,   IQR Notice of Participation Form ,   IQR Reconsideration Request Form ,   CAUTI Validation Template ,   CDI Validation Template ,   CLABSI Validation Template 1Q18-2Q18 ,   MRSA Validation Template ,   Validation Review for Reconsideration Request ,   VBP Appeal Request Form ,   HVBP CMS Independent Review Form ,   CLABSI Validation Template 3Q17-4Q17 ,   Validation Educational Review Form

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: We are proposing to modify our previously finalized eCQM reporting requirements such that hospitals would be required to report 2 self-selected calendar quarters of data for 6 of the available eCQMs for the CY 2017 reporting period/FY 2019 payment determination and to report the first three calendar quarters (Q1-Q3) of data for 6 of the available eCQMs for the CY 2018 reporting period/FY 2020 payment determination. This change has caused a decrease in burden. The decrease in burden is 31,475.

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Annual Cost to Federal Government: $10,326,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/19/2017

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