CMS-10250.HOQR CY 2025 Supporting Statement Part B_final

Supporting Statement - Part B

Submission of Information for the Hospital Outpatient Quality Reporting (OQR) Program

Collection of Information Employing Statistical Methods

1. Describe potential respondent universe.

All subsection (d) hospitals receiving reimbursement under the Outpatient Prospective Payment System (OPPS) in the United States; approximately 3,200 hospitals.

2. Describe procedures for collecting information.

Data are collected from quality data codes (QDCs) entered on Medicare non-institutional claims via the CMS-1500 form. Data may be patient-level, or summary or aggregate data submitted directly to CMS via a secure web portal (currently, the Hospital Quality Reporting (HQR) system), or the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) by either the hospital or their authorized vendor(s), as specified.

3. Describe methods to maximize response rates.

To maximize response rates, the Hospital OQR Program provides for payment consequences related to program participation. Specifically, hospitals that do not meet program requirements will receive a 2.0 percentage point reduction to their OPPS annual payment update. In an effort to reduce burden and thereby maximize response rates, the Hospital OQR Program allows HOPDs to sample for measures that require direct data entry (i.e., Median Time for Discharged ED Patients; Cataract Visual Function; Stroke, and Appropriate Follow-up Interval for Colonoscopy). In addition, CMS provides abstraction and submission tools, education and outreach, and technical assistance to any hospitals needing assistance with program requirements.

4. Describe any tests of procedures or methods.

1. Sampling for Chart-Abstracted Data for the Hospital OQR Program

In an effort to reduce burden, for measures that require direct data entry under the Hospital OQR Program hospitals may submit a representative sample of the denominator population instead of including all eligible cases. A sample may consist of either 63 cases for hospitals with a population size between 0 and 900, or 96 cases for hospitals with a population size of greater than 900, but they are able to submit more if they so choose. Hospitals that choose to sample must ensure that the sampled data represents their outpatient population by using either simple random sampling or systematic random sampling, and that the sampling techniques are applied consistently within a quarter. For example, quarterly samples for a sampling population must use consistent sampling techniques across the quarterly submission period. Hospitals may also submit measure data for the entire applicable patient population in lieu of sampling.

2. Validation Policy for Chart-Abstracted Data for the Hospital OQR Program

CMS selects 500 hospitals for validation; 450 are selected randomly, and the remaining 50 are selected using targeting criteria on an annual basis for validation. Each hospital will be required to submit up to 12 cases per quarter and 48 cases per year. To be eligible for random selection for validation, a hospital must have submitted at least 12 encounters to the Hospital OQR Program Clinical Warehouse during the quarter containing the most recently available data. The quarter containing the most recently available data is defined based on when the random sample is drawn. To be eligible for targeted selection for validation, the hospital must be a subsection (d) hospital and meet one or more of the following criteria:

• any hospital which failed the validation requirement that applied to the previous year's payment determination;

• any hospital having an outlier value for a measure, e.g. a measure value that appears to deviate markedly from the measure values for other hospitals;

• any hospital with outlier values indicating specifically poor scores on a measure;

• any hospital that has not been randomly selected for validation in any of the previous 3 years;

• any hospital that passed validation in the previous year but had a two-tailed confidence interval that included 75 percent; and

• any hospital with less than four quarters of data subject to validation due to receiving an Extraordinary Circumstance Exceptions (ECE) for one or more quarters and with a two-tailed confidence interval that is less than 75 percent.

After the random selection has been completed, the CMS Clinical Data Abstraction Center (CDAC) sends record requests by a trackable mail method to the designated Medical Record Contact at the hospital. Each hospital is required to submit the requested documentation to the CDAC within 30 calendar days of the date of the request (as documented on the request letter). If the hospital fails to comply within 30 days, a “zero” score is assigned to each data element for each selected case, and the case will fail for all measures in the same topic.

3. Validation Response Rates for the Hospital OQR Program

To ensure consistently high response rates from selected hospitals for validation, the CMS-designated contractor provides a 15-day reminder notice to hospitals that have outstanding medical records. In addition, during the last week of the submission period, CMS provides a daily list of hospitals with outstanding records to the CMS-designated contractor who then makes targeted phone calls to the hospitals.

Once the CDAC receives the requested medical documentation, it independently re-abstracts the same quality measure data elements that the hospital previously abstracted and submitted, and it compares the two sets of data to determine whether they match. A confidence interval using a binomial approach is used in the calculation of validation scores to account for sample variability and the possibility of small sample sizes, and that data being analyzed are binary (match, do not match). To receive a full annual payment update, hospitals must obtain at least a 75 percent validation score for the designated time-period based upon this validation process.

5. Provide name and telephone number of individuals consulted on statistical aspects.

Kimberly Go, MPA Grace Snyder, JD, MPH 

410-786-4560 410-786-0700