CMS-10210 Inpatient Withholding Data form

Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Overview
Hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program agree to have data
publicly reported on Hospital Compare. Hospitals not participating in the Hospital IQR Program with an
Optional Public Reporting Notice of Participation (NOP) have the option to withhold data from public
reporting on Hospital Compare, for those measures listed in Table 1.
Hospitals participating in the Hospital IQR Program, Hospital Value-Based Purchasing (VBP) Program,
Hospital Readmissions Reduction Program, and/or Hospital-Acquired Condition (HAC) Reduction
Program can submit a request for CMS review to withhold data from public reporting on Hospital
Compare, for those measures listed in Table 2.

Request Form Submission Information
Please complete the applicable sections of this form and fax or email the completed form to the Hospital
Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor.
Secure fax:
1-877-789-4443
Email:
[email protected]

Contact Information
All hospitals must provide the required contact information; required fields are marked with an asterisk (*).

Hospital/Health System Specifics
*Hospital Name:

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*CMS Certification Number (CCN):

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*Street Address:

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*City, State, ZIP Code:

(blank)

*Hospital Contact Name:

(blank)

*Hospital Contact Phone Number:

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2017 Hospital Compare Release

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Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Hospital/Health System Chief Executive Officer (or designee)
*Name:

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*Title:

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*Date:

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*Signature:

Instructions for Completing the Withholding Form
This section of the form provides the instructions for completing the withholding form and is divided into
subsections for those hospitals not participating in the Hospital IQR Program and those hospitals included
in the Hospital VBP, Hospital Readmissions Reduction, and/or HAC Reduction Programs.

Hospitals Not Participating in Hospital IQR Program
The following information is applicable only to those hospitals not participating in the Hospital IQR
Program with an Optional Public Reporting NOP.
This form must be received no later than August 10, 2017, for hospitals not participating in the Hospital
IQR Program with an Optional Public Reporting NOP.
NOTE: Forms received after the end of the preview period will not be considered for the October 2017
Hospital Compare release.
My hospital has reviewed its Preview Report. For this preview period, we wish to withhold from
public reporting data submitted for the measure(s) as indicated below.
Hospitals not participating in the Hospital IQR Program with an Optional Public Reporting NOP may
suppress any or all of the measures listed in the following table, by marking the Suppress column.
Table 1: Measures for Suppression for Hospitals Not Participating in Hospital IQR Program
Measure ID
STK-4
VTE-5
VTE-6
ED-1b
ED-2b
IMM-2
2017 Hospital Compare Release

Measure Name
Thrombolytic Therapy
Venous Thromboembolism Warfarin Therapy Discharge
Instructions
Hospital Acquired Potentially-Preventable Venous
Thromboembolism

Suppress

Median Time from Emergency Department (ED) Arrival
to ED Departure for Admitted ED Patients
Admit Decision Time to ED Departure Time for
Admitted Patients
Influenza Immunization
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Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Measure ID
PC-01
STRUCTURAL_
SAFE_SURG
STRUCTURAL_
NURSING
STRUCTURAL_ GEN_SURG
HCAHPS
MORT-30-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
READM-30-AMI
READM-30-CABG
READM-30-COPD
READM-30-HF
READM-30-PN
READM-30-STK
READM-30-HOSPWIDE
READM-30-HIP-KNEE

COMP-HIP-KNEE
EDAC-30-AMI

2017 Hospital Compare Release

Measure Name

Suppress

Elective Delivery
Safe Surgery Checklist Use
Participation in a Systematic Clinical Database Registry
for Nursing Sensitive Care
Participation in a Systematic Clinical Database Registry
for General Surgery
Hospital Consumer Assessment of Healthcare Providers
and Systems Survey
Acute Myocardial Infarction (AMI) 30-Day Mortality
Rate
30-Day Mortality Following Coronary Artery Bypass
Graft (CABG) Surgery
Chronic Obstructive Pulmonary Disease (COPD) 30Day Mortality Rate
Heart Failure (HF) 30-Day Mortality Rate
Pneumonia 30-Day Mortality Rate
Acute Ischemic Stroke 30-Day Mortality Rate
Acute Myocardial Infarction (AMI) 30-Day
Readmission Rate
30-Day Readmission Following Coronary Artery Bypass
Graft (CABG) Surgery
Chronic Obstructive Pulmonary Disease (COPD) 30Day Readmission Rate
Heart Failure (HF) 30-Day Readmission Rate
Pneumonia 30-Day Readmission Rate
Acute Ischemic Stroke 30-Day Readmission Rate
30-Day Hospital-Wide All-Cause Unplanned
Readmission Rate
30-Day Readmission Rate Following Elective Primary
Total Hip Arthroplasty (THA) and/or Total Knee
Arthroplasty (TKA)
Complication Rate Following Elective Primary Total
Hip Arthroplasty (THA) and/or Total Knee Arthroplasty
(TKA)
Excess Days in Acute Care after Hospitalization for
Acute Myocardial Infarction
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Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Measure ID
EDAC-30-HF
PAYM-30-AMI
PAYM-30-HF
PAYM-30-PN
PAYM-90-HIP-KNEE
PSI-3
PSI-4
PSI-6
PSI-8
PSI-9
PSI-10
PSI-11
PSI-12
PSI-13
PSI-14
PSI-15
PSI-90
IMM-3
EDV-1

2017 Hospital Compare Release

Measure Name
Excess Days in Acute Care after Hospitalization for
Heart Failure
Risk-Standardized Payment Associated with a 30-Day
Episode-of-Care for Acute Myocardial Infarction
Risk-Standardized Payment Associated with a 30-Day
Episode-of-Care for Heart Failure
Risk-Standardized Payment Associated with a 30-Day
Episode-of-Care for Pneumonia
Risk-Standardized Payment Associated with a 90-Day
Episode of Care for THA/TKA

Suppress

Pressure Ulcer Rate
Death rate among surgical inpatients with serious
treatable complications
Iatrogenic pneumothorax, adult
In-Hospital Fall With Hip Fracture Rate
Postoperative Hemorrhage or Hematoma Rate
Postoperative Acute Kidney Injury Requiring Dialysis
Rate
Postoperative Respiratory Failure Rate
Perioperative Pulmonary Embolism (PE) or Deep Vein
Thrombosis (DVT)
Postoperative Sepsis Rate
Postoperative wound dehiscence
Unrecognized Abdominopelvic Accidental
Puncture/Laceration Rate
Patient Safety and Adverse Events (modified composite)
Healthcare Personnel Influenza (HCP) Vaccination
Emergency Department Volume

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Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Hospitals Participating in Hospital IQR, Hospital VBP, Hospital Readmissions
Reduction, and/or HAC Reduction Programs
The following information is applicable only to those hospitals participating in the Hospital IQR, Hospital
VBP, Hospital Readmissions Reduction, and/or HAC Reduction Programs.
NOTE: Forms received after the end of the program-specific Preview Period or Review and Corrections
period will not be considered.
My hospital has reviewed its Preview Report and/or Review and Corrections Report. We wish to
request a review to withhold from public reporting data submitted for the program(s) and
measure(s) as indicated below.
Hospitals participating in the Hospital IQR Program, Hospital VBP Program, Hospital Readmissions
Reduction Program, and/or HAC Reduction Program may request CMS review to suppress any or all of the
measures listed in the following table, by marking the Suppress column and indicating the Reporting
Program(s).
Table 2: Measures for Suppression for Hospitals Participating in Hospital IQR, Hospital
VBP, Hospital Readmissions Reduction, and/or HAC Reduction Programs1
Measure ID
MORT-30-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
READM-30-AMI
READM-30-CABG
READM-30-COPD

1

Measure Name
Acute Myocardial Infarction (AMI) 30Day Mortality Rate

Suppress

30-Day Mortality Following Coronary
Artery Bypass Graft (CABG) Surgery
Chronic Obstructive Pulmonary Disease
(COPD) 30-Day Mortality Rate
Heart Failure (HF) 30-Day Mortality
Rate
Pneumonia 30-Day Mortality Rate
Acute Ischemic Stroke 30-Day
Mortality Rate
Acute Myocardial Infarction (AMI) 30Day Readmission Rate
30-Day Readmission Following
Coronary Artery Bypass Graft (CABG)
Surgery
Chronic Obstructive Pulmonary Disease
(COPD) 30-Day Readmission Rate

Program(s)
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Suppression does not exempt a hospital from receiving a payment adjustment.

2017 Hospital Compare Release

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Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Measure ID

Measure Name
Heart Failure (HF) 30-Day
READM-30-HF
Readmission Rate
Pneumonia 30-Day Readmission Rate
READM-30-PN
Acute Ischemic Stroke 30-Day
READM-30-STK
Readmission Rate
30-Day Hospital-Wide All-Cause
READM-30Unplanned Readmission Rate
HOSPWIDE
30-Day Readmission Rate Following
Elective Primary Total Hip
READM-30-HIP-KNEE
Arthroplasty (THA) and/or Total Knee
Arthroplasty (TKA)
Complication Rate Following Elective
Primary Total Hip Arthroplasty (THA)
COMP-HIP-KNEE
and/or Total Knee Arthroplasty (TKA)
Excess Days in Acute Care after
Hospitalization for Acute Myocardial
EDAC-30-AMI
Infarction
EDAC-30-HF
PAYM-30-AMI

PAYM-30-HF

PAYM-30-PN

PAYM-90-HIP-KNEE
PSI-3
PSI-4
PSI-6
PSI-7

2017 Hospital Compare Release

Excess Days in Acute Care after
Hospitalization for Heart Failure
Risk-Standardized Payment Associated
with a 30-Day Episode-of-Care for
Acute Myocardial Infarction
Risk-Standardized Payment Associated
with a 30-Day Episode-of-Care for
Heart Failure
Risk-Standardized Payment Associated
with a 30-Day Episode-of-Care for
Pneumonia
Risk-Standardized Payment Associated
with a 90-Day Episode of Care for
THA/TKA
Pressure Ulcer Rate
Death rate among surgical inpatients
with serious treatable complications
Iatrogenic pneumothorax, adult
Central Venous Catheter-Related
Bloodstream Infection Rate (Hospital
VBP only)

Suppress

Program(s)
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Hospital Compare
Request for Withholding Data from Public Reporting Form
2017
Measure ID
PSI-8

PSI-9
PSI-10
PSI-11
PSI-12
PSI-13
PSI-14

PSI-15

PSI-90

Measure Name
In-Hospital Fall With Hip Fracture Rate
(in the modified composite);
Postoperative Hip Fracture Rate
(Hospital VBP only)
Postoperative Hemorrhage or
Hematoma Rate
Postoperative Acute Kidney Injury
Requiring Dialysis Rate
Postoperative Respiratory Failure Rate
Perioperative Pulmonary Embolism
(PE) or Deep Vein Thrombosis (DVT)
Postoperative Sepsis Rate
Postoperative wound dehiscence
Unrecognized Abdominopelvic
Accidental Puncture/Laceration Rate (in
the modified composite);
Accidental Puncture or Laceration Rate
(Hospital VBP only)
Patient Safety and Adverse Events
(modified composite);
Patient Safety for Selected Indicators
(Hospital VBP only)

Suppress

Program(s)

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Justification

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. Please do not send applications, claims, payments, medical records, or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If
you have questions or concerns regarding where to submit your documents, please contact the Hospital IQR Support Contractor at
(844) 472-4477. Expiration Date: xx/xx/xxxx

2017 Hospital Compare Release

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