CMS-10210 Extraordinary Circumstances Form

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
A facility may request an exception, as specified by CMS, for the submission of quality reporting and valuebased purchasing program data due to extraordinary circumstances beyond the facility’s control. These
circumstances may include (but are not limited to) natural disasters (such as a severe hurricane or flood),
issues with CMS-designated information systems that directly affect the ability of the facility to submit data,
or extreme circumstances that prevent facilities from electronic clinical quality measure (eCQM) or
electronic health record (EHR)-based reporting. Please refer to the Federal Register and Code of Federal
Regulations for program-specific rules on availability of this exception. To request an exception, please
complete and submit this form.
For extraordinary circumstances affecting the submission of data, this form must be submitted within 90
calendar days of the extraordinary circumstance, except in cases related to the submission of
eCQMs under the Hospital Inpatient Quality Reporting and Hospital Outpatient Quality Reporting
Programs which have an ECE Request deadline of April 1 following the end of the reporting period. At
the latest, you should submit your ECE form no later than 90 days from the submission deadline for the
quarter requested.
An asterisk (*) indicates required fields. All sections must be complete and specific in order for
the CMS to consider the request.
____________________________________________________________________________________
Facility Contact Information
*Facility Name
*CMS Certification Number (CCN)
*National Provider Identifier Number (NPI) (ASC only)
(Place additional NPIs in Additional Comments section.)
*CEO/Designee Contact Information
*Name ______________________________________ *Title _______________________________
*Address (must include physical street address) __________________________________________
*City ____________________________________ *State _________________ *Zip Code ________
*Telephone Number _____________________________ *Extension _________________________
*Email Address ___________________________________________________________________
Additional Contact Information
Name _________________________________________ Title _________________________________
Address (must include physical street address)_______________________________________________
City_______________________________________ State _____ ZIP Code_______________________
Telephone Number________________________ Extension____________________________________
Email Address_________________________________________________________________________
*Dates
*Date of Request

May 2024

*Date of Extraordinary Circumstance ______________________

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
*Program(s) and Program Requirement(s) for Which Facility is Requesting Exception
Please indicate which program requirement(s) and reporting period(s) for each requirement which you are
requesting exception for an extraordinary circumstance.
Program
Ambulatory
Surgical
Center Quality
Reporting
(ASCQR)
Program

Measure and/or Program Requirement

Reporting
Periods

☐ National Healthcare Safety Network (NHSN) Measures
☐ Web-based Measure(s)

☐ Patient-Reported Outcome-Based Performance Measure(s) (PRO-PMs)

☐ Outpatient and Ambulatory Surgical Consumer Assessment of Healthcare Providers
and Systems (OAS CAHPS)
☐ Other (Please specify):

_______________________________________________________________________
End-Stage
Renal
Disease
Quality
Incentive
Program
(ESRD QIP)

☐ In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems
(ICH CAHPS) Survey
☐ National Healthcare Safety Network (NHSN)
☐ ESRD Quality Reporting System (EQRS)
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
HospitalAcquired
Condition
(HAC)
Reduction
Program

☐ National Healthcare Safety Network (NHSN) Measures

Hospital
Inpatient
Quality
Reporting
(IQR)
Program

☐ Chart-abstracted Measure(s)

☐ Validation
☐ Other (Please specify):

_______________________________________________________________________
☐ Electronic Clinical Quality Measures (eCQMs)
☐ Hybrid Measure(s)

☐ Patient-Reported Outcome-Based Performance Measure(s)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey
National Healthcare Safety Network (NHSN) Measures
☐ Influenza Vaccination Coverage Among Healthcare Personnel

☐ COVID-19 Vaccination Coverage Among Health Care Personnel

☐ Patient Safety Structural Measure
☐ Web-based Measure(s)

May 2024

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Program

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Measure and/or Program Requirement

Reporting
Periods

☐ Population and Sampling

☐ Chart-abstracted Validation
☐ eCQM Validation

☐ Other (Please specify):

_______________________________________________________________________
Hospital
Outpatient
Quality
Reporting
(OQR)
Program

☐ Chart-abstracted Measure(s)
☐ Web-based Measure(s)

☐ National Healthcare Safety Network (NHSN) Measures
☐ Electronic Clinical Quality Measures (eCQMs)

☐ Patient-Reported Outcome-Based Performance Measure(s)

☐ Outpatient and Ambulatory Surgical Consumer Assessment of Healthcare Providers
and Systems (OAS CAHPS)
☐ Validation

☐ Other (Please specify):

_______________________________________________________________________
Hospital
Readmissions
Reduction
Program
(HRRP)

☐ Other (Please specify):

Hospital
Value-Based
Purchasing
(VBP)
Program

☐ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey

_______________________________________________________________________

☐ NHSN Healthcare-associated infection (HAI) Measure(s)

☐ Severe Sepsis and Septic Shock Management Bundle (Composite Measure)
☐ Other (Please specify):
_______________________________________________________________________

Inpatient
Psychiatric
Facility
Quality
Reporting
(IPFQR)
Program

☐ Chart-abstracted Measure(s)
☐ Web-based Measure(s)

☐ National Healthcare Safety Network (NHSN) Measure(s)
☐ Chart-abstracted Measure(s)
☐ Other (Please specify):

_______________________________________________________________________
Rural
Emergency
Hospital
Quality
Reporting
(REHQR)
May 2024

☐ Chart-abstracted Measure(s)
☐ Web-based Measure(s)
☐ Other (Please specify):

_______________________________________________________________________
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Program

Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form
Measure and/or Program Requirement

Reporting
Periods

Program
PPS-Exempt
Cancer
Hospital
Quality
Reporting
(PCHQR)
Program

☐ Web-based Measure(s)

☐ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey
☐ National Healthcare Safety Network (NHSN) Measure(s)
☐ Other (Please specify):

_______________________________________________________________________

Exception or Extension Request Information
*Date ECE relief would end
*Provide justification for the ECE end date.

May 2024

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form

*Enter specific reasons for requesting an exception. Please include the specific requirements or data
for which you are seeking an exception. Please indicate how the extraordinary circumstance prevented
your facility from submitting accurate data for the measure(s) for which an exception is being sought
(if applicable). Attach supporting documentation when necessary.

*Provide evidence of the impact of the extraordinary circumstance including (but not limited to)
photographs, web links, newspaper, and other media articles. Attach supporting documentation
when necessary.

May 2024

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form

Additional Comments (Attach additional documentation/comments if necessary.)

*CEO/Designee Signature:

*Date:

Extraordinary Circumstances Exceptions Request Form Submission Instructions
Complete and submit this form, via the Hospital Quality Reporting Secure Portal, Managed File Transfer to
[email protected]. You may instead submit via email to [email protected] or
secure fax to (877) 789-4443.
Following receipt of the request form, CMS will (1) Provide a written acknowledgement using the contact
information provided in the request, to the CEO and any additional designated facility personnel, notifying
them that the facility’s request has been received and (2) provide a formal response to the CEO and any
additional designated facility personnel using the contact information provided in the request notifying them of
our decision. CMS will strive to complete its review of each ECE request within 90 calendar days of receipt of
the request.
PRA Disclosure Statement

May 2024

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Centers for Medicare & Medicaid Services (CMS) Quality Program
Extraordinary Circumstances Exceptions (ECE) Request Form

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 01-31-2026). The time required to complete this information
collection is estimated to average 15 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 Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support
Contractor at (844) 472-4477.

May 2024

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