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Federal forms, ICRs, and supporting documents

Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 201905-0938-008 · OMB 0938-1022.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10210
Quality Measures and Procedures for Hospital Reporting of Quality Data		 Form and Instruction
CMS-10210 Data Accuracy and Completeness Form
IPPS_Data Accuracy Completeness Acknowledgement (April 2019) (508).pdf 		Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form
HVBP_Review_and_Corrections_Request_Form_Final_April2018.(508)ff.pdf 		Form and Instruction
CMS-10210 Extraordinary Circumstances Form
CMS Quality Program ECE Request Form (April 2019)(508).pdf 		Form and Instruction
CMS-10210 Hospital Compare Request Form for Withholding/Footnoting
Hospital Compare Withholding Footnoting Request Form (April 2019)(508).pdf 		Form and Instruction
CMS-10210 IQR Measure Exception Form
IPPS Measure Exception Form CY2020 Data (April 2019)(508).pdf 		Form and Instruction
CMS-10210 IQR Notice of Participation Form
IQR NOP and PR NOP Text (April 2019)(508).pdf 		Form and Instruction
CMS-10210 IQR Reconsideration Request Form
Quality Reporting Reconsideration Request Form (April 2019)(508).pdf 		Form and Instruction
CMS-10210 CAUTI Validation Template
FY2022_CAUTI_Validation Template_April 2019 (508).xlsx 		Form and Instruction
CMS-10210 CDI Validation Template
FY2022_CDI_Validation Template_April 2019 (508).xlsx 		Form and Instruction
CMS-10210 CLABSI Validation Template 1Q18-2Q18
FY2022_CLABSI_Validation Template_April 2019 (508).xlsx 		Form and Instruction
CMS-10210 MRSA Validation Template
FY2022_MRSA_Validation Template_April 2019 (508).xlsx 		Form and Instruction
CMS-10210 Validation Review for Reconsideration Request
IQR Validation Reconsideration Request Form (April 2019)(508).pdf 		Form and Instruction
CMS-10210 VBP Appeal Request Form
HVBP Appeal Request Form Final April2018.(508)ff.pdf 		Form and Instruction
CMS-10210 HVBP CMS Independent Review Form
HVBP CMS Independent Review Form_April2018_Final.(508)ff.pdf 		Form and Instruction
CMS-10210 Validation Educational Review Form
Quality Reporting Validation Educational Review Form (Apr 2018)ff(508).pdf 		Form and Instruction
Summary of HIQR Information Collection Forms - FY2020 IPPS Proposed Rule - Inpatient Quality Reporting PRA Package (April 2019).docx
Summary of Updates on HIQR Collection Forms		IC Document

Information Collection (IC) Details

View Information Collection (IC)

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Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10210 Data Accuracy and Completeness Form IPPS_Data Accuracy Completeness Acknowledgement (April 2019) (508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital VPB Review and Corrections Form HVBP_Review_and_Corrections_Request_Form_Final_April2018.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Extraordinary Circumstances Form CMS Quality Program ECE Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting Hospital Compare Withholding Footnoting Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Measure Exception Form IPPS Measure Exception Form CY2020 Data (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Notice of Participation Form IQR NOP and PR NOP Text (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 IQR Reconsideration Request Form Quality Reporting Reconsideration Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CAUTI Validation Template FY2022_CAUTI_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CDI Validation Template FY2022_CDI_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 CLABSI Validation Template 1Q18-2Q18 FY2022_CLABSI_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 MRSA Validation Template FY2022_MRSA_Validation Template_April 2019 (508).xlsx Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Review for Reconsideration Request IQR Validation Reconsideration Request Form (April 2019)(508).pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 VBP Appeal Request Form HVBP Appeal Request Form Final April2018.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 HVBP CMS Independent Review Form HVBP CMS Independent Review Form_April2018_Final.(508)ff.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10210 Validation Educational Review Form Quality Reporting Validation Educational Review Form (Apr 2018)ff(508).pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 17,600 0 0 0 0 17,600
Annual IC Time Burden (Hours) 1,612,710 0 -907,390 0 0 2,520,100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Summary of Updates on HIQR Collection Forms Summary of HIQR Information Collection Forms - FY2020 IPPS Proposed Rule - Inpatient Quality Reporting PRA Package (April 2019).docx 05/13/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.