Hospice Quality Reporting Program (CMS-10390)

OMB 0938-1153

OMB 0938-1153

Section 3004(c) of the Patient Protection and Affordable Care Act (ACA), (which added section 1814(i)(5) to the Social Security Act) ), authorized the Secretary to establish a quality reporting program for hospices. Section 1814(i)(5)(A)(i) of the Social Security Act required that the Secretary, beginning with FY 2014, reduce the market basket update by 2 percentage points for any hospice that does not submit quality data submission for a fiscal year. During the first "mandatory" reporting period, hospices were required to gather data pertaining to two quality measures: (1) a structural measure titled "Participation in a Quality Assessment and Performance Improvement (QAPI) Program that Includes at Least Three Quality Indicators Related to Patient Care" and; (2) the National Quality Forum (NQF)-endorsed #0209 pain measure. Hospice providers were then required to report their data between 01/01/2012 and 04/01/2012 In the CY 2013 HH PPS final rule (77 FR 67132 through 67136), CMS retained the two measures that had previously been adopted in the FY 2012 rule. Hospices will continue to collect data for these measures until December 31, 2013. Beginning on July, 1, 2014, hospices shall begin to collect quality measure data using a newly created set of data elements which are collectively titled as the "Hospice Item Set." The Hospice Item Set, which was developed specifically for use in the hospice setting, contains data elements that are used to collect standardized, patient-level data. This data can be used, at a later date, to calculate six NQF-endorsed quality measures and a modification of one NQF-endorsed measure. For more details about the Hospice Item Set, refer to Section 1 of the Supporting Statement A.

The latest form for Hospice Quality Reporting Program (CMS-10390) expires 2021-08-31 and can be found here.


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