60 Day Public Comment Response

June 7, 2019
VIA EMAIL
Owen Osaghae
Division of Provider Audit Operations
Centers for Medicare and Medicaid Services
[email protected]
RE:

Policy Recommendations on CMS Notice of Intern and Resident Information System
(IRIS) New XML File Format (FR Doc 2019-06884)

Dear Mr. Osaghae:
Greater New York Hospital Association (GNYHA) is writing to provide policy recommendations
regarding the new file format for the Intern and Resident Information System (IRIS) software. In
July 2018, GNYHA provided recommendations regarding the development of the new file format
while it was in development, based on input from a GNYHA workgroup comprised of finance and
graduate medical education (GME) staff.
GNYHA Background
As background, GNYHA is comprised of 160 hospitals and health systems in New York, New
Jersey, Connecticut, and Rhode Island. The vast majority of our member hospitals are teaching
institutions. GNYHA advocates on behalf of teaching hospital issues and our staff works closely
with hospital and health system leadership to ensure that they understand and can work with
policies and rules regarding GME reimbursement. GNYHA takes particular interest in ensuring
that our hospitals are able to navigate the complexities of Medicare GME payment policy.
GNYHA Comments
In general, GNYHA was pleased that many of the recommendations that our members put forth as
part of the GNYHA workgroup were included in the new XML file format. We were particularly
pleased that CMS included new fields where hospitals could list training occurring in psychiatry
and rehabilitation medicine units. We were also pleased to see that the new file format will provide
an opportunity for teaching hospitals to identify residents who train in certain “clinical base years”
who may have participated in an advanced match to a specialty program.
With regard to the new XML file format, GNYHA offers the following comments. In doing so,
we make specific reference to the document entitled, Interns and Residents Information System
(IRIS) XML General Instructions.

Initial Residency Program Type Code (page 3)
The draft instruction states at the end of the initial paragraph, “Note that this [reporting the program
code associated with first day of first rotation after medical school] still applies even for residents
going into additional residency programs, whether first residency is completed or not.”
We believe the intent of the clause “whether first residency is completed or not” is to indicate that,
even in a situation where a resident switches a residency program prior to completion, the initial
residency period (IRP) for the resident does not change. If that is what is intended, we would
suggest the language be modified slightly to something closer to, “Note that the residency code
remains the same where a resident continues training in an advanced residency program or
switches into a different residency program, regardless of whether the first residency program
entered into was completed.”
CMS Response
The proposed language is clearer; we revised the IRIS instruction to reflect the proposed language.
Comment
The draft instruction states in the third paragraph that a hospital can report a residency code
different from the first residency program entered into in cases where a simultaneous match or an
advanced match occurs. We would suggest that this language can be simplified. CMS modified its
policy at 42 Code of Federal Regulations (CFR) 413.79(a)(10) to specify that, for cost reporting
periods that begin on or after October 1, 2005, a hospital need only document that the advanced
match occurred. Thus, the language could be modified to something closer to, “However, a resident
who, prior to beginning the first year of residency training, matched in a specialty program …”
and the section regarding the simultaneous match could be eliminated. The simultaneous match
rule was effectively superseded by the advanced match policy as part of Federal fiscal year 2006
rulemaking; we don’t believe there is a need to include that language for future IRIS submissions.
CMS Response
We revised the paragraph to make it clearer and reflect advanced matching.
Comment
With regard to the overall policy and file format regarding the advanced match policy, as noted in
our July 2018 comments, GNYHA also recommends that CMS establish a simple administrative
process whereby a hospital can request a modification to information incorrectly entered by
another hospital regarding the match issue. For example, the XML file format could include an
Amendment Form for use by a hospital that believes that residency program code information was
entered incorrectly by another hospital (and thus, “locked”). The hospital with correct residency
code information could complete the Amendment Form and supply documentation to support its
contention that the previously entered code residency program code should be corrected.
CMS Response
This comment is outside the proposed instruction for the XML IRIS format; we will take under
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advisement for future changes. The XML IRIS format is programmed to note specialties requiring
advanced matching as a prerequisite.
Comment
Assignment (Rotation Time) Period (page 7)
The draft instruction provides examples of how to calculate an assignment when a resident is
spending time within a block of time at multiple hospitals. Within these examples, the draft
instruction indicates that the hospital should use “GME percentage” and IME percentage” to divide
up a block of time and avoid duplications. In general, GNYHA agrees with the approach. What is
not clear to us, however, is the determination of total number of hours (the denominator) within
the example provided.
The example concerns a resident spending time in training at two hospitals (A and B) with 4 hours
per week spent at hospital B. For Option A, the draft instruction states, “Complete Percentage Base
where hospital A is reporting the rotational assignment time period for the resident as 1/1/15 –
1/31/15 at 94% (232 out of 248 hours)…” It is not clear to us where 248 hours comes from in this
scenario. Previous CMS policy guidance regarding the resident work week and associated number
of hours comprising a 1.0 full-time equivalent (FTE) has been based on the number of hours
normally expected for that particular program. For example, CMS noted in the context of
rulemaking, “we [CMS] would consider a ‘work week’ to be dependent on the specific residency
program in which the resident is training and the resident’s full-time or part-time status” (72 Fed.
Reg. 162, page 47379 (August 22, 2007). If that is the methodology that is being used, GNYHA
recommends that the example and description of the scenario state that and the option in particular
needs to include a more detailed explanation of how the total number of hours was calculated.
CMS Response
We agree with the comment. We have noted that the normal total work week is dependent on the
number of hours expected for a specific residency program. We also noted that the 248 hours was
calculated assuming 8 hours a day for 31 days.
Comment
Assignment Residency Type Code (page 11)
The draft instruction makes an important distinction between residency specialty and setting for
training that we believe can be better stated. The instruction states at the end of the first paragraph,
“For example, if a resident in the Internal Medicine program rotates to the Acute Hospital’s
psychiatric sub-hospital unit, report the residency code for Internal Medicine rather than for
Psychiatry.” We believe the distinction that needs to be emphasized in this example would be
illustrated better by something closer to, “For example, if a resident in the Internal Medicine
program rotates to the Acute Hospital’s psychiatric sub-hospital unit, the residency code for that
assignment is reported as Internal Medicine but the time in training would be reported as part of
the IPF (Psych) Teaching Adjustment Percentage.”
CMS Response
We added clarification to state that the applicable residency code for the example is internal
medicine and not psychiatry. The question of how the time would be allocated is addressed in the
“Assignment (Rotation) Time Period” field.
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Comment
Displaced Resident (page 13)
The draft instruction states that there will be a separate field for a hospital to indicate whether a
particular resident is a “displaced resident” covered under the policies specified under 42 CFR
413.79(h). As with the field for New Programs within the Assignment record, GNYHA
recommends that the accompanying instructions here also note that the assignment would meet the
exception to the rolling average rules.
CMS Response
The commenter suggestion is outside the scope of the IRIS instruction. The Medicare cost report
instruction addresses how the rolling average is calculated.

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Page 1 of 2

PUBLIC SUBMISSION

As of: 6/11/19 11:23 AM
Received: June 07, 2019
Status: Draft
Tracking No. 1k3-9aci-tz77
Comments Due: June 07, 2019
Submission Type: Web

Docket: CMS-2019-0062
Indirect Medical Education and Supporting Regs.(R-64)
Comment On: CMS-2019-0062-0001
Agency Information Collection Activities; Proposals, Submissions, and Approvals
Document: CMS-2019-0062-DRAFT-0002

Submitter Information
Name: Luke DiSabato

General Comment
Comment
The following are comments regarding CMS-R-64, Indirect Medical Education and Direct
Graduate Medical Education (OMB 0938-0456). The documents state there are various tables
available in an accompanying table (the Residency Type Code Table, The Medical School
Codes Table) which is not included in the new released document for the XML files. The tables
now included on the CMS website shows just residency type codes but the years to complete
the residency program is not published and this is needed to ensure the vendors have the
appropriate amounts in their tables to agree to what CMS is calculating for the FTEs. The
current Medical School Codes Table is outdated as there are at least 5 schools not in the table.
This also needs to be updated and released to ensure appropriate data is accumulated.
CMS Response
CMS is in the process of updating the residency codes for new specialty programs, and new
medical schools. The updated tables will be available on the IRIS webpage on the CMS.Gov
website. The updated residency code table will include years to complete each residency
program. Please note that CMS does not set the years needed to complete any of the residency
programs; the residency programs accrediting organizations set the minimum number of years
required for board certification.
Comment
There should be a public list of edits that CMS will be applying to the IRIS XML submission
to ensure the files are applying the same edits prior to submission.

Page 2 of 2

CMS Response
CMS plan to publish the IRIS validation file on the IRIS webpage after OMB approval of the
IRIS XML format. We have attached a copy of validation file to this posting.

Comment
Once the Final Notice is completed, there needs to be instruction on the date of transition to the
XML files and whether the amended IRIS files from previous cost reports can be submitted
with the old DBF format or the XML file is required. The IRIS data from previous years do not
have all the new fields introduced in the XML.
CMS Response
CMS will give the IRIS vendors 6 months to program the new IRIS using the XML format after OMB
approval of the IRIS format. Also, there will be a transition period from the old IRIS format to the
new XML format, after which the old format would be retired. Providers would be able to file their
IRIS data using both the XML and DBF format during the transition period.