CMS-10210 Hospital Compare Request Form for Withholding/Footnoting

Hospital Compare
Request Form for Withholding/Footnoting Data for Public Reporting
Overview
Hospitals and other facilities participating in the Hospital Inpatient Quality Reporting (IQR) Program,
Hospital Outpatient Quality Reporting (OQR) Program, PPS-Exempt Cancer Hospital Quality Reporting
(PCHQR) Program, Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program, Ambulatory
Surgical Center Quality Reporting (ASCQR) Program, Hospital Value-Based Purchasing (HVBP) Program,
Hospital Readmissions Reduction Program (HRRP), and/or Hospital-Acquired Condition (HAC) Reduction
Program, respectively, agree to have data publicly reported on Hospital Compare. Hospitals voluntarily
publicly reporting inpatient data on Hospital Compare with an Optional Public Reporting Notice of
Participation have the option to withhold data from public reporting on Hospital Compare, for those
measures listed in Table 1.
Hospitals and other facilities participating in the Hospital IQR Program, Hospital OQR Program, PCHQR
Program, IPFQR Program, ASCQR Program, HVBP Program, HRRP, and/or HAC Reduction Program can
submit a request for CMS review to add a footnote to claims-based measure data included in public
reporting on Hospital Compare, for those measures listed in Table 2.

Request Form Submission Information
Please complete the applicable sections of this form and fax or email the completed form to the Hospital
Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor via:
Secure fax:
1-877-789-4443
Email:
[email protected]

Contact Information
All hospitals and facilities must provide the required contact information; required fields are marked with
an asterisk (*).

Facility/Hospital Specifics
*Facility Name:

(

*CMS Certification Number
(CCN)/National Provider Identifier
(NPI):

(blank)

*Street Address:

(blank)

*City, State, ZIP Code:

(blank)

*Facility Contact Name:

(blank)

*Facility Contact Phone Number:

(blank)

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Hospital Compare
Request Form for Withholding/Footnoting Data for Public Reporting
Facility/Hospital Chief Executive Officer (or designee)
*Name:

(blank)

*Title:

(blank)

*Date:

(blank)

*Signature:

Withholding/Footnoting Form
This section of the form provides the instructions for completing the withholding/footnoting form and is
divided into subsections for those hospitals voluntarily participating in inpatient public reporting on
Hospital Compare and those hospitals and facilities included in the Hospital IQR, Hospital OQR, PCHQR,
IPFQR, ASCQR, HVBP, HRRP, and/or HAC Reduction Programs.

Hospitals Voluntarily Participating in Inpatient Public Reporting
The following information is applicable only to those hospitals voluntarily participating in inpatient public
reporting on Hospital Compare with an Optional Public Reporting Notice of Participation.
This form must be received no later than the last day of the applicable preview period, for hospitals not
participating in public reporting on Hospital Compare with an Optional Public Reporting Notice of
Participation.
NOTE: Forms received after the end of the preview period will not be considered for that Hospital
Compare release.
My hospital has reviewed its Preview Report. For this preview period, we wish to withhold from
public reporting data submitted for the measure(s) as indicated below.
Hospitals voluntarily participating in inpatient public reporting on Hospital Compare with an Optional
Public Reporting Notice of Participation may withhold any or all of the measures listed in the following
table, by marking the Withhold column.
Table 1: Inpatient Measures for Withholding for Hospitals Voluntarily Participating in
Public Reporting
Measure ID
IMM-2
IMM-3/HCP
ED-1b
ED-2b
MORT-30-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
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Withhold

Measure ID

Withhold

PSI 3
PSI 4
PSI 6
PSI 8
PSI 9
PSI 10
PSI 11
PSI 12
PSI 13
PSI 14
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Hospital Compare
Request Form for Withholding/Footnoting Data for Public Reporting
Measure ID

Withhold

READM-30-AMI
READM-30-CABG
READM-30-COPD
READM-30-HF
READM-30-PN
READM-30-HOSPWIDE
READM-30-HIP-KNEE
COMP-HIP-KNEE
EDAC-30-AMI
EDAC-30-HF
EDAC-30-PN
PAYM-30-AMI
PAYM-30-HF
PAYM-30-PN

Measure ID

Withhold

PSI 15
PSI 90
PC-01
SEP-1
HCAHPS
HAI-1 (CLABSI)
HAI-2 (CAUTI)
HAI-3 (SSI: Colon)
HAI-4 (SSI: Hysterectomy)
HAI-5 (MRSA)
HAI-6 (C. diff.)
PAYM-90-HIP-KNEE
MSPB

Facilities Participating in Hospital IQR, OQR, PCHQR, IPFQR, ASCQR, HVBP,
HRRP, and/or HAC Reduction Programs
The following form is intended to allow facilities to request a footnote be added to their data on the
Hospital Compare website in the event that the facility identifies errors in their claims-based measure data
during the preview or review and correction period. The footnote would be added to the data and would
indicate that the facility has identified errors in their data. NOTE: Forms received after the end of the
applicable program-specific Preview Period or Review and Corrections Period will not be considered.
My facility has reviewed its Preview Report and/or Review and Corrections Report. We wish to
request CMS review to add a footnote to public reporting data calculated for the program(s) and
measure(s) as indicated below.
Facilities may request CMS review to footnote any or all of the claims-based measures listed in the
following table, by marking the Footnote column for the requested measure(s).
Table 2: Measures for Footnoting 1
Measure ID
MORT-30-AMI
MORT-30-CABG
MORT-30-COPD
MORT-30-HF
MORT-30-PN
MORT-30-STK
READM-30-AMI
READM-30-CABG
READM-30-COPD
READM-30-HF
READM-30-HOSPWIDE
READM-30-PN
READM-30-HIP-KNEE

1

Footnote

Measure ID

Footnote

PSI 10
PSI 11
PSI 12
PSI 13
PSI 14
PSI 15
PSI 90
MSPB
OP-8
OP-9
OP-10
OP-11
OP-13

Footnoting does not affect a facility’s payment adjustment.

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Hospital Compare
Request Form for Withholding/Footnoting Data for Public Reporting
Measure ID
COMP-HIP-KNEE
EDAC-30-AMI
EDAC-30-HF
EDAC-30-PN
PAYM-30-AMI
PAYM-30-HF
PAYM-30-PN
PAYM-90-HIP-KNEE
PSI 3
PSI 4
PSI 6
PSI 8
PSI 9

Footnote

Measure ID

Footnote

OP-14
OP-32
FUH-7
FUH-30
READM-30-IPF
PCH-30
PCH-31
ASC-1
ASC-2
ASC-3
ASC-4
ASC-12

Justification
In order to review your request for footnoting of claims-based measures, you will need to submit the
following information in the box below:
•
•
•

Provide the number of claims that are impacted, including the encounter dates.
Provide a description of the problem.
Provide the plan to fix the claims in error.

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 0938-1022 (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, MD 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.

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