Hospital Reporting Initiative--Hospital Quality Measures (CMS-10210)

Forms and Documents

Document Name	Status
Form CMS-10210 Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Modified
CMS-10210 HIQR_Supporting Statement B_clean 5-10-22.docx Supporting Statement B	2022-06-06
CMS-10210 (HIQR)_Supporting Statement A_clean (5-10-2022).docx Supporting Statement A	2022-06-06

IC Document Collections

IC ID	Document Title	Status
204350	Quality Measures and Procedures for Hospital Reporting of Quality Data Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1022	ICR Reference No: 202206-0938-004
Status: Received in OIRA	Previous ICR Reference No: 202109-0938-012
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Hospital Reporting Initiative--Hospital Quality Measures (CMS-10210)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/06/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2022
Responses	18,000	17,600
Time Burden (Hours)	1,772,318	1,572,810
Cost Burden (Dollars)	0	0

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Abstract: In the FY 2023 IPPS/LTCH PPS proposed rule, we are proposing to adopt the following measures: (1) the Hospital Commitment to Health Equity structural measure, beginning with the CY 2023 reporting period/FY 2025 payment determination; (2) the Screening for Social Drivers of Health measure, beginning with voluntary reporting for the CY 2023 reporting period and mandatory reporting beginning with the CY 2024 reporting period/FY 2026 payment determination; (3) the Screen Positive Rate for Social Drivers of Health process measure, beginning with voluntary reporting for the CY 2023 reporting period and mandatory reporting beginning with the CY 2024 reporting period/FY 2026 payment determination; and (4) the Hospital-Level, Risk-Standardized Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty (THA/TKA) performance measure (THA/TKA PRO–PM), beginning with voluntary reporting across two periods (July 1, 2023 through June 30, 2024 and July 1, 2024 through June 30, 2025), followed by mandatory reporting of the measure for the reporting period which runs from July 1, 2025 through June 30, 2026, impacting the FY 2028 payment determination. We are proposing a modification to our eCQM reporting and submission requirements whereby we are increasing the total number of eCQMs to be reported from four to six eCQMs beginning with the CY 2024 reporting period/FY 2026 payment determination.

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Authorizing Statute(s): PL: Pub.L. 109 - 171 5001(a) Name of Law: Hospital Quality Improvement
   PL: Pub.L. 108 - 173 5001(b) Name of Law: Medicare Prescription Drug, Improvement and Modernization Act of 2003
   PL: Pub.L. 111 - 148 3001 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AU84	Proposed rulemaking	87 FR 28108	05/10/2022

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Quality Measures and Procedures for Hospital Reporting of Quality Data	CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210, CMS-10210	Data Accuracy and Completeness Form ,   Hospital VPB Review and Corrections Form ,   Extraordinary Circumstances Form ,   Hospital Compare Request Form for Withholding/Footnoting Data for Public Reporting ,   IQR Measure Exception Form ,   IQR Notice of Participation Form ,   IQR Reconsideration Request Form ,   Validation Review for Reconsideration Request ,   VBP Appeal Request Form ,   HVBP CMS Independent Review Form ,   Validation Educational Review Form ,   Maternal Morbidity Structural Measure ,   Perinatal Care (PC)-01 Measure ,   Population and Sampling

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	18,000	17,600	0	400	0	0
Annual Time Burden (Hours)	1,772,318	1,572,810	0	199,508	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been an increase in burden hours of 199,508.

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Annual Cost to Federal Government: $10,370,469

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/06/2022

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