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

Forms and Documents

Document Name	Status
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Unchanged
IQR Final Rule Comments and Responses.docx Supplementary Document	2020-10-30
CMS-10210 HIQR Supporting Statement B_FY 2021 9-29-20.docx Supporting Statement B	2020-10-30
CMS-10210 FY 2021 HIQR Supporting Statement A 9-29-20.docx Supporting Statement A	2020-10-30

IC Document Collections

IC ID	Document Title	Status
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Unchanged

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 202010-0938-013
Status: Received in OIRA	Previous ICR Reference No: 202004-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
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	Date Submitted to OIRA: 11/05/2020

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2022
Responses	17,600	17,600
Time Burden (Hours)	1,572,443	1,612,710
Cost Burden (Dollars)	0	0

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Abstract: In the FY 2021 IPPS/LTCH PPS proposed rule, we are not proposing to add or remove any measures from the program. For eCQM reporting, we are proposing to progressively increase the numbers of quarters of eCQM data reported, from one self-selected quarter of data to four quarters of data over a three year period, by requiring hospitals to report two quarters of data for the CY 2021 reporting period/FY 2023 payment determination, three quarters of data for the CY 2022 reporting period/FY 2024 payment determination, and four quarters of data beginning with the CY 2023 reporting period/FY 2025 payment determination and for subsequent years. We are also proposing to streamline validation processes under the Hospital IQR Program by aligning validation processes for chart-abstracted measures and eCQMs. We would do this by aligning hospital selection, including: (i) reducing the pool of hospitals randomly selected for chart-abstracted measure validation; and (ii) integrating and applying targeting criteria for eCQM validation.

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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-AU11	Final or interim final rulemaking	85 FR 58432	09/18/2020

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

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

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	Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting ,   IQR Measure Exception Form ,   IQR Notice of Participation Form ,   IQR Reconsideration Request Form ,   Hospital VPB Review and Corrections Form ,   Data Accuracy and Completeness Form ,   Extraordinary Circumstances Form ,   Validation Review for Reconsideration Request ,   HVBP CMS Independent Review Form ,   Validation Educational Review Form ,   VBP Appeal Request Form

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ICR Summary of Burden

	Total Request	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)	1,572,443	1,612,710	0	-40,267	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: For the CY 2021 reporting period/FY 2023 payment determination, the total annual burden is estimated to be 1,572,443 hours at a cost of approximately $61 million. This change in burden is associated with the policy finalized in the FY 2021 IPPS/LTCH final rule to increase the number of reporting quarters for eCQMS from one to two quarters and the previously finalized policy in the FY 2019 IPPS Final Rule (83 FR 41478-83 FR 41484) to move the validation of HAI measures to the HACRP program that takes effect in CY 2021. The increase in reporting quarters from one quarter to two quarters between CY 2020 and CY 2021 is associated with a 2,933 hour increase in burden across IPPS and Non-IPPS hospitals. The removal of HAI measure validation from the IQR program is associated with a 43,200 hour reduction of burden. Those two changes result in a net 40,267 hour reduction in burden. The burden cost from CY 2020 to CY 2021 decreased from approximately $62.6 million to $61 million.

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Annual Cost to Federal Government: $10,357,989

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? No

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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: 11/05/2020

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