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

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 2019 IPPS Final Rule - HIQR Supporting Statement A (7-25-2018).docx Supporting Statement A	2018-12-14

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: 201812-0938-015
Status: Historical Active	Previous ICR Reference No: 201804-0938-021
Agency/Subagency: HHS/CMS	Agency Tracking No: CMS-10210
Title: Hospital Reporting Initiative--Hospital Quality Measures (CMS-10210)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/04/2019
	Date Received in OIRA: 12/14/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2022	36 Months From Approved	01/31/2020
Responses	17,600	0	17,600
Time Burden (Hours)	2,520,100	0	3,637,282
Cost Burden (Dollars)	0	0	0

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Abstract: In the FY 2019 IPPS/LTCH PPS proposed rule, we anticipate the following proposals would impact our previously approved burden estimate: (1) eCQM reporting and submission requirements for the CY 2019 reporting period/FY 2021 payment determination; (2) removal of eight chart-abstracted measures beginning with the CY 2019 reporting period/FY 2021 payment determination; and (3) removal of one chart-abstracted measure beginning with the CY 2020 reporting period/FY 2022 payment determination. In this PRA Package, we are requesting approval for a decrease in the total burden we expect to be experienced by approximately 4,400 participating hospitals (3,300 IPPS hospitals and 1,100 non-IPPS hospitals).

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3001 Name of Law: Affordable Care Act
   PL: Pub.L. 108 - 173 5001(b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   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-AT27	Final or interim final rulemaking	83 FR 41144	08/17/2018

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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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	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 ,   Validation Educational Review Form ,   Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting ,   Data Accuracy and Completeness Form ,   Hospital VPB Review and Corrections Form ,   Extraordinary Circumstances Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	17,600	17,600	0	0	0	0
Annual Time Burden (Hours)	2,520,100	3,637,282	0	-1,117,182	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: In total, we estimate: (1) a decrease of 1,046,071 hours (-741,074 hours for ED-1 and IMM-2 removal + -304,997 hours for VTE-6 removal) and approximately $38.3 million (1,046,071 hours x $36.58 per hour) across all 3,300 IPPS hospitals due to the finalized removal of three chart-abstracted measures; (2) a decrease of 71,044 hours (-65,853 hours for ED-1 and IMM-2 removal + -5,191 hours for VTE-6 removal) and approximately $2.6 million (71,044 hours x $36.58 per hour) across participating non-IPPS hospitals due to the finalized removal of three chart-abstracted measures; and (3) a decrease of 67 hours and approximately $2,400 due to the discontinuation of voluntary data collection of the Hybrid Hospital-Wide Readmission measure. In total for the FY 2021 payment determination, we estimate a burden decrease of approximately 1,117,182 hours (-1,046,071 hours + -71,044 hours + -67 hours) and approximately $41 million (-1,117,182 hours x $36.58 per hour) across all participating IPPS and non-IPPS hospitals due to the finalized changes set forth in the FY 2019 IPPS/LTCH PPS final rule.

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Annual Cost to Federal Government: $10,340,910

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 12/14/2018

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