Information Collection

Quality Measures and Procedures for Hospital Reporting of Quality Data

IC 204350 under ICR 202206-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 2. Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)_clean(508).pdf	Form and Instruction
CMS-10210 Data Accuracy and Completeness Form 2. Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)_clean(508).pdf	Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form 8. Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form(508)ff.pdf	Form and Instruction
CMS-10210 Hospital VPB Review and Corrections Form 8. Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form(508)ff.pdf	Form and Instruction
CMS-10210 Extraordinary Circumstances Form 7. CMS Quality Program ECE Request Form_CY 2023_clean(508)ff.pdf	Form and Instruction
CMS-10210 Extraordinary Circumstances Form 7. CMS Quality Program ECE Request Form_CY 2023_clean(508)ff.pdf	Form and Instruction
CMS-10210 Hospital Compare Request Form for Withholding/Footnoting 3. Care Compare Withholding Footnoting Request Form_CY 2023_tracked(508)ff.pdf	Form and Instruction
CMS-10210 Hospital Compare Request Form for Withholding/Footnoting 3. Care Compare Withholding Footnoting Request Form_CY 2023_tracked(508)ff.pdf	Form and Instruction
CMS-10210 IQR Measure Exception Form 4. IPPS Measure Exception Form for PC 01 and SSI Measures_clean(508)ff.pdf	Form and Instruction
CMS-10210 IQR Measure Exception Form 4. IPPS Measure Exception Form for PC 01 and SSI Measures_clean(508)ff.pdf	Form and Instruction
CMS-10210 IQR Notice of Participation Form 1. Hospital Inpatient Quality Reporting Notice of Participation_clean(508).pdf	Form and Instruction
CMS-10210 IQR Notice of Participation Form 1. Hospital Inpatient Quality Reporting Notice of Participation_clean(508).pdf	Form and Instruction
CMS-10210 IQR Reconsideration Request Form 5. CMS Quality Reporting Program APU Reconsideration Request Form_clean(508)ff.pdf	Form and Instruction
CMS-10210 IQR Reconsideration Request Form 5. CMS Quality Reporting Program APU Reconsideration Request Form_clean(508)ff.pdf	Form and Instruction
CMS-10210 Validation Review for Reconsideration Request 6. CMS Hospital IQR Program Validation Review for Reconsideration Request Form (508)ff.pdf	Form and Instruction
CMS-10210 Validation Review for Reconsideration Request 6. CMS Hospital IQR Program Validation Review for Reconsideration Request Form (508)ff.pdf	Form and Instruction
CMS-10210 VBP Appeal Request Form 9. Hospital Value-Based Purchasing (VBP) Program Appeal Request Form(508)ff.pdf	Form and Instruction
CMS-10210 VBP Appeal Request Form 9. Hospital Value-Based Purchasing (VBP) Program Appeal Request Form(508)ff.pdf	Form and Instruction
CMS-10210 HVBP CMS Independent Review Form 10. Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form(508)ff.pdf	Form and Instruction
CMS-10210 HVBP CMS Independent Review Form 10. Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form(508)ff.pdf	Form and Instruction
CMS-10210 Validation Educational Review Form 18. HQR_ValEdReviewForm_082021.pdf	Form and Instruction
CMS-10210 Validation Educational Review Form 18. HQR_ValEdReviewForm_082021.pdf	Form and Instruction
CMS-10210 Maternal Morbidity Structural Measure 11. Maternal Morbidity Structural Measure(508).pdf	Form and Instruction
CMS-10210 Maternal Morbidity Structural Measure 11. Maternal Morbidity Structural Measure(508).pdf	Form and Instruction
CMS-10210 Perinatal Care (PC)-01 Measure 12. PC-01 Measure(508).pdf	Form and Instruction
CMS-10210 Perinatal Care (PC)-01 Measure 12. PC-01 Measure(508).pdf	Form and Instruction
CMS-10210 Population and Sampling 13. Population and Sampling(508).pdf	Form and Instruction
CMS-10210 Population and Sampling 13. Population and Sampling(508).pdf	Form and Instruction
Summary of HQR Information Collection Forms - FY2023 IPPS Final Rule - HQR PRA Package (1).docx Summary of Updates on HIQR Collection Forms	IC Document
Summary of HQR Information Collection Forms - FY2023 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	Data Accuracy and Completeness Form	2. Hospital Quality Reporting Data Accuracy and Completeness Acknowledgement (DACA)_clean(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital VPB Review and Corrections Form	8. Hospital Value-Based Purchasing (VBP) Program Review and Corrections Request Form(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Extraordinary Circumstances Form	7. CMS Quality Program ECE Request Form_CY 2023_clean(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting	3. Care Compare Withholding Footnoting Request Form_CY 2023_tracked(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Measure Exception Form	4. IPPS Measure Exception Form for PC 01 and SSI Measures_clean(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Notice of Participation Form	1. Hospital Inpatient Quality Reporting Notice of Participation_clean(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	IQR Reconsideration Request Form	5. CMS Quality Reporting Program APU Reconsideration Request Form_clean(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Review for Reconsideration Request	6. CMS Hospital IQR Program Validation Review for Reconsideration Request Form (508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	VBP Appeal Request Form	9. Hospital Value-Based Purchasing (VBP) Program Appeal Request Form(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	HVBP CMS Independent Review Form	10. Hospital Value-Based Purchasing (VBP) Program Independent CMS Review Request Form(508)ff.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Validation Educational Review Form	18. HQR_ValEdReviewForm_082021.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Maternal Morbidity Structural Measure	11. Maternal Morbidity Structural Measure(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Perinatal Care (PC)-01 Measure	12. PC-01 Measure(508).pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10210	Population and Sampling	13. Population and Sampling(508).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: 4,500

Number of Respondents for Small Entity: 1,135

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	18,000	400	17,600
Annual IC Time Burden (Hours)	1,772,318	199,508	1,572,810
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 - FY2023 IPPS Final Rule - HQR PRA Package (1).docx	06/06/2022

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