Form 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-2), and Healthcare-Associated Infections
[Surgical Site Infection (SSI), Catheter-Associated Urinary Tract Infection
(CAUTI), Central Line-Associated Bloodstream Infection (CLABSI)]. This form is used
by the following programs: Hospital Inpatient Quality Reporting (IQR), Hospital ValueBased 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
July 1 through September 30

April 1 through June 30
October 1 through December 31

Emergency Department (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
July 1 through September 30

April 1 through June 30
October 1 through December 31

Specified Colon and Abdominal Hysterectomy Surgical Procedures
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.
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) _______

July 2018

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Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Reporting Programs
Measure Exception Form for PC, ED, and HAI Data Submission

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
Medical Ward
Medical/Surgical Ward
Surgical Ward
Pediatric Medical Ward
Pediatric Medical/Surgical Ward
Pediatric Surgical Ward

CDC Location Code
IN:ACUTE:WARD:M
IN:ACUTE:WARD:MS
IN:ACUTE:WARD:S
IN:ACUTE:WARD:M_PED
IN:ACUTE:WARD:MS_PED
IN:ACUTE:WARD:S_PED

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.
Catheter-Associated Urinary Tract Infection (CAUTI)
Hospital has no ICU locations and no Adult or Pediatric Medical, Surgical, or Medical/Surgical
wards.
Calendar Year (YYYY) ____________
January 1 through March 31
July 1 through September 30

April 1 through June 30
October 1 through December 31

Central Line-Associated Bloodstream Infection (CLABSI)
Hospital has no ICU locations and no Adult or Pediatric Medical, Surgical, or Medical/Surgical
wards.
Calendar Year (YYYY) ____________
January 1 through March 31
July 1 through September 30

July 2018

April 1 through June 30
October 1 through December 31

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Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Reporting Programs
Measure Exception Form for PC, ED, and HAI Data Submission

*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: ___________________________________________________________________
*Signature: __________________________________________________________________

Submission Instructions
Complete and submit this form via email to [email protected], secure fax to 877-7894443, 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 09381022 (Expires: xx-xx-xxxx).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 estimate(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, Maryland 21244-1850.
****CMS Disclosure**** 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 Inpatient Value,
Incentives, and Quality Reporting Outreach and Education Support Contractor at (844) 472-4477.

July 2018

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