Index of changes to forms

Summary of Hospital Inpatient Quality Reporting Information Collection Forms: Updates for the FY 2019 IPPS Proposed Rule

Form	Notes on Updates
Hospital Inpatient Quality Reporting Notice of Participation	Form resubmitted with updated hyperlinks and to clarify that optional public reporting does not impact payment determinations under the Hospital Inpatient Quality Reporting Program or other hospital quality programs.
Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)	Form resubmitted to update applicable program year and add reference to the Hospital-Acquired Condition Reduction and Hospital Value-Based Purchasing Programs, which would use Hospital IQR Program data collected for the FY 2020 payment determination.
Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting	Form resubmitted with refined title, to add/remove measures for the upcoming preview period and Hospital Compare release, including removal of measures proposed for immediate removal, to include the names of all applicable quality reporting and pay-for-performance programs, and to add option to request a footnote for claims-based measure data that are included in public reporting.
Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) Quality Reporting Programs Measure Exception Form for PC, ED, and HAI Data Submission	Form resubmitted to add a signature line for the designated provider personnel’s signature and to remove reference to the ED-1 measure, which will be removed from the program beginning with January 1, 2019 discharges.
CMS Quality Reporting Program APU Reconsideration Request Form	Form resubmitted to clarify instructions for submitting this request form.
CMS Hospital IQR Program Validation Review for Reconsideration Request Form	Form resubmitted to clarify instructions for submitting this request form and to add column for National Healthcare Safety Network Event ID number.
CMS Quality Reporting Validation Educational Review Form	Form resubmitted with refined title.
Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form	No updates/changes to previously submitted form. Form still in use.
Hospital Value-Based Purchasing (VBP) Program Appeal Request Form	No updates/changes to previously submitted form. Form still in use.
Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form	No updates/changes to previously submitted form. Form still in use.
Centers for Medicare & Medicaid Services (CMS) Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form	Form resubmitted with refined title and to add the Skilled Nursing Facility Value-Based Purchasing Program.
Validation Templates for CLABSI, CAUTI, MRSA, and CDI measures	Templates resubmitted to reflect the annual changes in fiscal year and beginning reporting quarter, as well as new CDC pathogen lists, with each new selection of hospitals for validation.

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