Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 202004-0938-009 · OMB 0938-1022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data	Form and Instruction
CMS-10210 Data Accuracy and Completeness Form Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA).pdf	Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form.pdf	Form and Instruction
CMS-10210 Extraordinary Circumstances Form CMS Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form.pdf	Form and Instruction
CMS-10210 Hospital Compare Request Form for Withholding/Footnoting Request Form for Withholding_Footnoting Data for Public Reporting.pdf	Form and Instruction
CMS-10210 IQR Measure Exception Form CMS IPPS Quality Reporting Programs Measure Exception Form for PC and HAI Data Submission.pdf	Form and Instruction
CMS-10210 IQR Notice of Participation Form Hospital Inpatient Quality Reporting Notice of Participation.pdf	Form and Instruction
CMS-10210 IQR Reconsideration Request Form CMS Quality Reporting Program APU Reconsideration Request Form.pdf	Form and Instruction
CMS-10210 Validation Review for Reconsideration Request CMS Hospital IQR Program Validation Review for Reconsideration Request Form.pdf	Form and Instruction
CMS-10210 VBP Appeal Request Form Hospital Value-Based Purchasing (VBP) Program Appeal Request Form.pdf	Form and Instruction
CMS-10210 HVBP CMS Independent Review Form Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form.pdf	Form and Instruction
CMS-10210 Validation Educational Review Form CMS Quality Reporting Validation Educational Review Form.pdf	Form and Instruction
Summary of HQR Information Collection Forms - FY2021 IPPS Final Rule - HQR PRA Package (1).docx Summary of Updates on HIQR Collection Forms	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Quality Measures and Procedures for Hospital Reporting of Quality Data

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10210	Validation Educational Review Form	CMS Quality Reporting Validation Educational Review Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital VPB Review and Corrections Form	Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Extraordinary Circumstances Form	CMS Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting	Request Form for Withholding_Footnoting Data for Public Reporting.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Measure Exception Form	CMS IPPS Quality Reporting Programs Measure Exception Form for PC and HAI Data Submission.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Notice of Participation Form	Hospital Inpatient Quality Reporting Notice of Participation.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Reconsideration Request Form	CMS Quality Reporting Program APU Reconsideration Request Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Review for Reconsideration Request	CMS Hospital IQR Program Validation Review for Reconsideration Request Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	VBP Appeal Request Form	Hospital Value-Based Purchasing (VBP) Program Appeal Request Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP CMS Independent Review Form	Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Data Accuracy and Completeness Form	Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA).pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,400

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	17,600	0	17,600
Annual IC Time Burden (Hours)	1,572,443	-40,267	1,612,710
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Summary of Updates on HIQR Collection Forms	Summary of HQR Information Collection Forms - FY2021 IPPS Final Rule - HQR PRA Package (1).docx	05/12/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.