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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10210 Validation Educational Review Form	Form and Instruction	Modified	Available
Form CMS-10210 HVBP CMS Independent Review Form	Form and Instruction	Modified	Available
Form CMS-10210 VBP Appeal Request Form	Form and Instruction	Modified	Available
Form CMS-10210 Validation Review for Reconsideration Request	Form and Instruction	Modified	Available
Form CMS-10210 MRSA Validation Template	Form and Instruction	Modified	Available
Form CMS-10210 CLABSI Validation Template 1Q18-2Q18	Form and Instruction	Modified	Available
Form CMS-10210 CDI Validation Template	Form and Instruction	Modified	Available
Form CMS-10210 CAUTI Validation Template	Form and Instruction	Modified	Available
Form CMS-10210 IQR Reconsideration Request Form	Form and Instruction	Modified	Available
Form CMS-10210 IQR Notice of Participation Form	Form and Instruction	Modified	Available
Form CMS-10210 IQR Measure Exception Form	Form and Instruction	Modified	Available
Form CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting	Form and Instruction	Modified	Available
Form CMS-10210 Extraordinary Circumstances Form	Form and Instruction	Modified	Available
Form CMS-10210 Hospital VPB Review and Corrections Form	Form and Instruction	Modified	Available
Form CMS-10210 Data Accuracy and Completeness Form	Form and Instruction	Modified	Available
CMS-10210 HIQR PRA Package - Supporting Statement A 12-20-2019.docx	Supporting Statement A	Uploaded 2019-12-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Validation Educational Review Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	HVBP CMS Independent Review Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	VBP Appeal Request Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Validation Review for Reconsideration Request
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	MRSA Validation Template
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	CLABSI Validation Template 1Q18-2Q18
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	CDI Validation Template
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	CAUTI Validation Template
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	IQR Reconsideration Request Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	IQR Notice of Participation Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	IQR Measure Exception Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Extraordinary Circumstances Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Hospital VPB Review and Corrections Form
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction	Modified	Data Accuracy and Completeness Form

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 201910-0938-001
Status: Historical Active	Previous ICR Reference No: 201905-0938-008
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 with change	Conclusion Date: 12/23/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/30/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	02/28/2022
Responses	17,600	0	17,600
Time Burden (Hours)	1,612,710	0	2,520,100
Cost Burden (Dollars)	0	0	0

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Abstract: In the FY 2020 IPPS/LTCH PPS proposed rule, we are proposing to adopt the Hybrid Hospital-Wide Readmission Measure With Claims and Electronic Health Record Data (NQF #2879).

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Authorizing Statute(s): PL: Pub.L. 109 - 171 5001(a) Name of Law: Hospital Quality Improvement
   PL: Pub.L. 108 - 173 5001(b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   PL: Pub.L. 111 - 148 3001 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT73	Final or interim final rulemaking	84 FR 42044	08/16/2019

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

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

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ICR Summary of Burden

table that charts list 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)	1,612,710	2,520,100	0	-907,390	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: We previously requested and received approval for total annual burden estimates under this OMB control number for the CY 2019 reporting period/FY 2021 payment determination of 2,520,100 hours as a result of policies finalized in the FY 2019 IPPS/LTCH PPS final rule. Additionally, we previously submitted total annual burden estimates under this OMB control number for the CY 2020 reporting period/FY 2022 payment determination of 1,612,710 hours – a total burden decrease of 907,390 hours – as a result of policies finalized 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: 10/30/2019

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