2021 Hospital IQR Program Requirements

CMS made some significant changes to the eCQM requirements for the IQR program, which can be found in their 2021 IPPS final rule. You'll want to pay special attention to that category in this post. 

History of the IQR program

As a reminder, the Hospital IQR program began in Fiscal Year (FY) 2010 to promote public transparency of quality. It is still technically considered “voluntary” but hospitals are incentivized to “volunteer” if they want to receive their full Annual Payment Update (APU) from Medicare (our nation’s first “Pay for Performance or P4P” program).

Hospitals who do not participate, or who participate but fail to meet program requirements are subject to a 25% reduction of their yearly APU increase and are excluded from participation in the Hospital VBP Program, which is the only one of the CMS value-based programs where you can actually make money. 

Which Hospitals Are Eligible?

All acute care hospitals that are paid for providing services to Medicare beneficiaries (including Veterans Hospitals) may participate except Psychiatric, Rehab, Children’s, Cancer and Long-Term Care Hospitals. Critical Access Hospitals are exempt but are permitted and encouraged to participate because they are also required to participate in the Medicare Promoting Interoperability program. Maryland Hospitals do not participate in the Hospital IQR program.

2021 IQR Requirements Summary

These mandatory requirements are due quarterly:

1. Submit two chart-abstracted measures (Clinical Process of Care measures)

2. Submit population and sampling numbers (for chart-abstracted measures only)

3. Submit HCAHPS survey data

These mandatory requirements are due annually:

4. Submit four Electronic Clinical Quality Measures (eCQMs)

5. Complete the Data Accuracy and Completeness Acknowledgement (DACA)

6. Submit one Healthcare-Associated Infection (HAI) measure

You must also:

7. Regularly review your claims-based data

8. Meet audit requirements if selected for audit (validation).

1. Submit Two Chart-Abstracted Measures Quarterly

CMS did not make any changes to the 2021 chart-abstracted measure requirements.

2021 Chart Abstracted Measure Requirements

	REQUIREMENT:  Hospitals must report on two chart-abstracted measures.
	SUBMISSION METHOD: QualityNet Secure Portal (Third party vendor authorization required.)
	DEADLINE: Quarterly Submission Deadlines

Hospitals with five or fewer discharges

Hospitals with five or fewer discharges (both Medicare and non-Medicare combined) per measure in a quarter are not required to submit patient-level data.

PC-01 measure submission

Hospitals are required to enter PC-01 measure data through the web-based tool on a quarterly basis. These data are manually entered. They cannot be transmitted via xml file. If you do not deliver babies at your organization, you must enter zeroes for the PC-01 measure each quarter or you can submit an IPPS Measure Exception form.

2. Submit Population and Sample Size Data Quarterly

	REQUIREMENT:  Hospitals must submit population and sampling numbers for all chart-abstracted measures.
	SUBMISSION METHOD: QualityNet Secure Portal (Third party vendor authorization required.)
	DEADLINE: Quarterly Submission Deadlines

*Exact date TBD.

Hospitals must submit aggregate population and sample size counts for each chart-abstracted measure. This requirement only applies to populations for the chart-abstracted measures. It must be completed quarterly through the QualityNet Secure Portal.

Hospitals with five or fewer discharges

If you have five or fewer discharges per measure (Medicare and non-Medicare combined) in a quarter you are not required to submit patient-level data for that measure for that quarter. However, you must submit the aggregate population and sample size counts even if the population is zero. Leaving a field blank does not fulfill the requirement.

3. Report HCAHPS Data Quarterly

	REQUIREMENT:  Hospitals must report Patient Experience of Care Survey measures data.
	SUBMISSION METHOD: QualityNet Secure Portal
	DEADLINE: Quarterly Submission Deadlines

Other considerations for the HCAHPS Survey

Hospitals with six or more HCAHPS-eligible discharges in a month must submit the total number of HCAHPS-eligible cases for the month as part of the quarterly survey data submission.

Hospitals with five or fewer HCAHPS-eligible discharges in a month are not required to submit the HCAHPS survey for that month.

If you have no HCAHPS-eligible discharges in a month, you must submit a zero for that month as a part of the quarterly data submission.

4. On an Annual Basis, Submit Two Quarters of Data for Four eCQMs 

eCQMs requirements have been ramped up over the next couple of years. In 2021, you must submit two quarters of data instead of the usual one quarter of data. By 2022, you must submit three quarters and by 2023, you must submit a full year of eCQM data.

One big change here is that your 2021 eCQM performance will be publicly reported and eventually on Hospital Compare. 

2021 eCQM Requirements

	REQUIREMENT:  Hospitals must report two quarters of data for at least four of the available 8 eCQMs.
	SUBMISSION METHOD: QualityNet Secure Portal (Third party vendor authorization required.)
	DEADLINE: February 28, 2022

eCQM List 2021

*The Opioid measure will be required for submission in 2022 and beyond.

Additional eCQM requirements

Your vendor/EHR must be certified to the 2015 Edition of Certified EHR Technology (CEHRT) for reporting in 2021. Your vendor/EHR must also be certified to for all eight eCQMs regardless of which eCQMs you submit.

All data must be submitted using the QRDA (Quality Reporting Document Architecture) Category 1 file format. File submission must include one QRDA 1 file per patient, per quarter that contains all episodes of care and the measures associated with the patient file.

Hospitals must use the most recent version of the eCQM specifications.

Hospitals must use a combination of factors to successfully complete their eCQM requirements. If you have at least five cases in the Initial Patient Population and have no zeros in your denominators for the measures you are submitting, you have successfully met the requirements for submission. If, however, you do not have at least five cases in the Initial Patient Population field, you must submit a Case Threshold Exemption form. If your measure has zero in the denominator you must submit a Zero Denominator Declaration form.

Other considerations for eCQM submission

By submitting your eCQMs to the IQR program, you will also successfully meet your CQM requirement for the Promoting Interoperability (Meaningful Use) program. 

5. On an Annual Basis, Complete the DACA

	REQUIREMENT:  Hospitals must complete the Data Accuracy and Completeness Acknowledgment (DACA).
	SUBMISSION METHOD: QualityNet Secure Portal
	DEADLINE: Annual Submission Deadline between between April 1 - May 15, 2022

The Data Accuracy and Completeness Acknowledgment (DACA) is a requirement for hospitals participating in the IQR program. The DACA is a method of electronically attesting that the data they submitted to the program is accurate and complete to the best of their knowledge. You can attest anytime between April and mid-May of 2022. Hospitals may complete the DACA within the QualityNet Secure Portal.

6. On an Annual Basis, Report One HAI Measure

This year, there weren't any changes to this category, but remember it went through a significant shift in 2020. If you'll remember in our post about which measures are being retired, we explained that the Healthcare Associated Infection (HAI) measures were almost all removed from the IQR program but retained in both the Hospital Value-Based Purchasing and Hospital-Acquired Condition Reduction programs. That leaves just one measure for you to submit annually now: the Influenza Vaccination measure.

2021 HAI Measure Requirements

	REQUIREMENT:  Hospitals must report on one HAI measure.
	SUBMISSION METHOD: National Healthcare Safety Network (NHSN) Portal
	DEADLINE: Annual Submission Deadline

7. Review your Claims-Based Data

In a nutshell hospitals will receive a score for their performance on 6 Claims-Based Outcome measures and 4 Claims-Based Payment Measures. No additional data submission is required to calculate the claims measure rates. CMS uses enrollment data, as well as Part A and Part B claims data, to calculate the measure rates.

	REQUIREMENT:  Hospitals are evaluated for their performance on seven Claims-Based Outcome measures and four Claims-Based Payment measures.
	SUBMISSION METHOD: No additional submission is required.
	DEADLINE: No submission deadline

• Submissions would be required no later than the first business day 3 months following the end of the reporting period
• Validation processes not yet established (expected in future rulemaking)
• Results for first mandatory submission will be posted on Hospital Compare in July of 2025

You will receive a Hospital-Specific Reports (HSRs) from CMS for these Claims-Based measures in the QualityNet Secure Portal. These reports contain discharge-level data, hospital-specific results and state and national results for comparison.

8. Fulfill Validation/Audit Requirements If Selected

There is a big change for audits in 2021. In short, CMS is combining the audits for chart-abstracted measures, eCQMs and HAC measures into one audit. So basically the audits for abstracted and HACs that usually include Q3 and Q4 of one year and Q1 and Q2 of the next year are shortened to only include Q3 and Q4. This gets all of the audits on the eCQM schedule which is the straight calendar year. 

Sorry if that was confusing. Here are the charts to sort it out. It'll make sense at the end.

HAC, Abstracted and eCQM hospital audit schedule

CMS will use measure data from only these quarters for both the random and targeted validation pools.

Aligning the number of hospitals selected for audits:

And speaking of random and targeted pools. CMS aligned the programs related to the number of hospitals selected too. Here are the charts.

Submission deadline:

For the FY 2024 program year and subsequent years, CMS will use measure data from all of 2021 for both the HAC Reduction Program and the Hospital IQR Program. Under this approach, the data submission deadlines for chart-abstracted measures will be in the middle of the month, the fifth month following the end of the reporting quarter.

Getting Quality Management Help

Medisolv has worked with many hospitals from the very beginning of their quality improvement process. We’ve felt their frustration and understand their concerns. But we can assure you that we can get you through this process and provide long-term support as the regulations and requirements change.

Not making a plan is still a plan, but not a sustainable one. Yearly penalty assessments will become steeper and accumulate.

Medisolv’s ENCOR Quality Reporting and Management software solution provides hospitals with the tools they need to meet all the CMS IQR reporting requirements. In addition to the software, our solution provides your hospital with expert clinical consultants that will guide your hospital through implementation, validation and submission. Unlike other companies, we do the heavy lifting for you when it comes to submission.

Learn about ENCOR >>