IQR Program Rule History

2024 

59144 

• Adopted 3 new eCQMs (HH-PI, HH-AKI, ExRad) 
• Refined 3 measures (COVID-19 Vaccination HCP, Hybrid HWM, Hybrid HWR) 
• Removed 3 measures (PC-01, MSPB, HIP-Knee-COMP) 
• Refined HCAHPS 
• Added additional criteria for targeted validation 

2023

CMS-1771

Volume 87

49190

·       Adopted 10 new measures (HCHE, SDOH-1, SDOH-2, ePC-02,
ePC-07/SMM, HH-ORAE, GMCS, THA/TKA PRO-PM, MSPB,
COMP-HIP-KNEE)

·       Refined 2 measures (THA/TKA Payment, AMI Excess Days)

·       Increased the number of required eCQMs

·       Removed zero-denominator declaration option for hybrid measures

·       Modified the eCQM validation

·       Adopted the Maternity Care designation for public reporting

2022

CMS-1752

Volume 86

25561

·       Adopted 5 new measures (Maternal Morbidity, Hybrid HWM, COVID-19 Vaccination HCP, HH-01, and HH-02)

·       Removed 3 eCQMs (PC-05, ED-2, and STK-06)

·       Required the use of the 2015 Cures Update

·       Replaced the term “Security Administrator” with “Security Official”

·       Updated the validation educational review process

2021

CMS-1735

Volume 85

58926

·       Incrementally increased the number of required eCQMs

·       Adopted the public reporting of eCQMs

·       Streamlined the validation process

2020

CMS-1716

Volume 84

42448

·       Adopted the Safe Use of Opioids and Hybrid HWR measures

·       Removed the READM-30-HWR measure

·       Extended the eCQM reporting and submission requirements

·       Established reporting and submission requirements for the
hybrid measures

2019

CMS-1694

Volume 83

41538

·       Adopted a new measure removal factor

·       Removed the HAI measures from Hospital IQR Program

·       Removal of 39 measures over 4 years:

o   CY 2018: 17 CBMs and 2 structural measures

o   CY 2019: 3 chart-abstracted measures and 2 CBMs

o   CY 2020: 6 chart-abstracted, 7 eCQMs, and 1 CBM

o   CY 2021: 1 CBM

2018

CMS-1677

Volume 82

38323

·       Refined the HCAHPS and Stroke Mortality measures

·       Adopted the Hybrid HWR measure

·       Modified eCQM reporting and submission requirements

·       Adopted policies for eCQM validation

·       Changed the name of the Extraordinary Circumstance Extension and Exemption to Extraordinary Circumstances Exception

2017

CMS-1655

Volume 81

57111

·       Removed 13 eCQMs (AMI-2, AMI-7a, AMI-10, HTN, PN-6,
SCIP-Inf-1a, SCIP-Inf-2a, SCIP-Inf-9, STK-4, VTE-3, VTE-4, VTE-5,
VTE-6) and 2 structural measures (Nursing Sensitive Care Registry and General Surgery Registry)

·       Refined the PSI 90 and PN Excess Days measures

·       Added 4 CBMs (AA Payment, Chole and CDE Payment,
SFusion Payment, and PN Excess Days)

·       Modified the eCQM reporting and submission policies

·       Modified the validation process to include eCQMs

·       Modified the ECE policy to extend the deadline from 30 to 90 days and a separate deadline for eCQM ECEs

2016

CMS-1632

Volume 80

49640

·       Updated the measures removal and retention policy

·       Removed 9 chart-abstracted measures (STK-1, STK-6, STK-8, VTE-1, VTE-2, VTE-3, IMM-1, SCIP-Inf-4)

·       Refined 2 measures (PN Mortality and PN Readmission CBMs)

·       Added 6 CBMs (AMI Excess Days, HF Excess Days, THA/TKA, Kidney/UTI, Cellulitis, & GI Payment) and 1 structural measure
(Patient Safety Culture)

·       Modified the eCQM reporting and submission policies

·       Modified the validation process

·       Adopted the use of the ECE form for eCQMs

2015

CMS-1607

Volume 79

50202

·       Finalized a total of 63 measures for Hospital IQR Program
(47 required and 16 voluntary)

·       Added new measures: 1 chart-abstracted (SEP-1), 4 CBMs
(CABG Readmission, CABG Mortality, PN Payment, HF Payment), and 6 voluntary eCQMs (EDHI-1a, PC-05, CAC-3, Healthy Term
Newborn, AMI 2, AMI-10)

·       Removed 19 chart-abstracted measures (AMI-1, 3, 5, 8a, HF-2,
PN-6, SCIP-Inf-1, 2, 3, 4, 6, 9, SCIP-Card-2, SCIP-VTE-2, STK-2, 3, 5, 10, VTE-4)

·       Outlined the “Topped Out” criteria for measures

·       Aligned the reporting and submission of eCQMs with the
Medicare EHR Incentive Program

·       Updated the validation process

2014

CMS-1599

Volume 78

50775

·       Removed 7 measures: 6 charted abstracted (PN-3b, HF-1,
AMI-2, AMI-10, HF-3, SCIP-INF-10) and 1 structural measure
(Stroke Care Registry)

·       Suspended the IMM-1 measure

·       Adopted 5 CBMs (COPD Readmission & Mortality, STK Readmission & Mortality, AMI Payment)

·       Finalized the proposal that hospitals would have until 11:59 p.m. Pacific Time to submit data

·       Updated the administrative process

·       Updated the NOP process

·       Updated the validation process

2013

CMS-1588

Volume 77

53503

·       Reduced the number of measures from 72 to 59

·       Removed 1 chart-abstracted measure (SCIP-VTE-1) and 16 CBMs
(8 HAC, 3 AHRQ IQI, 5 AHRQ PSI)

·       Added 3 CBMs (Hip/Knee Comp, Hip/Knee Readmission, HWR),
1 chart-abstracted measure (PC-01), and 1 structural measure
(Safe Surgery Checklist)

·       Added 3 Care Transition measures into HCAHPS

·       Adopted the IPPS Measure Exception form for CAUTI, CLABSI,
and SSI

·       Finalized the measure retention policy

·       Finalized the retainment of having 4 ½ months after the end of the submission quarter to submit data

·       Adopted a sub-regulatory process to make non-substantial changes

·       Updated the NOP policy

·       Finalized the proposal to align the structural measures and DACA with the final submission quarter for each fiscal year for fiscal year 2015 and subsequent years

·       Updated the validation process

·       Adopted the term “removed” for when a measure is retired

2012

CMS-1518

Volume 76

51605

·       Codified Hospital IQR Program procedural requirements at
42 CFR 412.140

·       Removed 4 chart-abstracted measures (AMI-4, HF-4, PN-4, PN-5c)

·       Suspended 4 measures (AMI-1, AMI-3, AMI-5, SCIP-Inf-6)

·       Added new chart-abstracted (STK and VTE measure sets), NHSN (CAUTI, MRSA, C diff, Influenza HCP), CBM (MSPB), and Structural (General Surgery Registry) measures

·       Adopted policy: If a hospital has 5 or fewer discharges for a quarter, it is not required to submit patient-level data.

·       Continue policy of providing hospitals with 14 days after the population & sampling deadline to submit patient-level files

·       Finalized additional HCAHPS requirements

·       Finalized the deadline for annual requirements to be the same as the Q4 requirement deadlines

·       Updated the NOP process

·       Updated validation process

·       Updated the reconsideration process including clarification: Hospitals have 30 days from date of notification to submit a recon.

2011

CMS-1498

Volume 75

50180

(RHQDAPU)

·       Removed 2 chart-abstracted measures (PN-2, PN-7) and the Mortality for Selected Procedure Composite measure

·       Added 2 AHRQ Safety measures (PSI 11, PSI 12), 8 HAC measures,
5 chart-abstracted measures (AMI-Statin at Discharge, ED-1, ED-2, Flu Immunization, PN Immunization), and 1 HAI (CLABSI) measure

·       Outlined the NOP process

·       Updated validation process

·       Adopted the ECE process

·       Outlined the reconsideration and appeals process

2010

CMS-1406

Volume 74

43860

·       Combined the PSI 04 and Nursing Sensitive – Failure to Rescue measures into the AHRQ PSI & Nursing Sensitive Care measure

·       Adopted 2 chart-abstracted measures (SCIP-Inf-9 and SCIP-Inf-10)

·       Adopted 2 structural measures (Stroke Care Registry and Nursing Sensitive Care Registry)

·       Adopted the DACA

2009

CMS-1390

Volume 73

48597

·       Adopted 12 new measures: chart-abstracted (PN-5c, SCIP-Card-2, STK measure set, VTE measure set), claims-based (AMI, HF, PN readmission), AHRQ (PSI, IQI, IQI Composite), Nursing Sensitive,
and Cardiac Surgery measures

·       Removed the Pneumonia Oxygenation measure

·       Adopted aggregate population and sample size submission requirements

2008

CMS-1533

Volume 72

66875

·       Added 4 new chart-abstracted measures (SCIP-Inf-4, SCIP-Inf-6, SCIP-Inf-7, SCIP-Card-2) and 1 new claims-based (PN Mortality) measure

·       Outlined the CART tool

2007

CMS-1488

Volume 71

48029

·       Amended regulations to reflect an increase in the APU reduction from 0.4 to 2.0 percent

·       Expanded the measure sets

·       Adopted: Hospitals have 4 ½ months after the end of the quarter to submit data.

·       Outlined the implementation of the HCAHPS measure

2006

CMS-1500

Volume 70

47420

·       No substantive updates

·       Addressed the non-contractual agreement with vendors

·       Outlined the specifications manual releases

2005

CMS-1428

Volume 69

49078

·       Outlined the RHQDAPU program

·       Adopted the 0.4 percent APU reduction

AA

aortic aneurysm

HTN

Hypertension

AHRQ

Agency for Healthcare Research and Quality

HWM

Hospital-Wide Mortality

AMI

acute myocardial infarction

HWR

Hospital-Wide Readmission

APU

annual payment update

IMM

immunization

C diff

Clostridioides difficile

Inf

infection

CABG

coronary bypass graft

IPPS

inpatient prospective payment system

CAC

Children’s Asthma Care

IQI

Inpatient Quality Indicators

Card

cardiac

IQR

Inpatient Quality Reporting

CART

CMS Abstraction Reporting Tool

LTCH

Long-Term Care Hospital

CAUTI

Catheter-associated urinary tract infection

MRSA

Methicillin-resistant Staphylococcus aureus

CBM

claims-based measure

MSPB

Medicare Spending Per Beneficiary

CDE

common duct exploration

NHSN

National Healthcare Safety Network

CFR

Code of Federal Regulations

NOP

Notice of Participation

Chole

cholecystectomy

ORAE

Opioid-Related Adverse Events

CLABSI

Central Line-Associated Bloodstream Infection

PC

perinatal care

CMS

Centers for Medicare & Medicaid Services

PM

performance measure

COMP

complication

PN

pneumonia

COPD

chronic obstructive pulmonary disease

PPS

Prospective Payment System

CY

calendar year

PRO

patient reported outcome

DACA

Data Accuracy and Completeness Acknowledgement

PSI

patient safety indicator

ECE

extraordinary circumstance exception

Q

quarter

eCQM

electronic clinical quality measures

READM

readmission

ED

emergency department

RHQDAPU

Reporting Hospital Quality Data for Annual
Payment Update

EHDI

Early Hearing Detection and Intervention

SCIP

Surgical Care Improvement Project

EHR

electronic health record

SDOH

social drivers of health

ePC

electronic perinatal care

SEP

sepsis

GI

gastrointestinal

SFusion

spinal fusion

GMCS

Global Malnutrition Composite Score

SMM

severe maternal morbidity

HAC

Hospital-Acquired Condition

SSI

surgical site infection

HAI

Healthcare-Associated Infections

STK

stroke

HCAHPS

Hospital Consumer Assessment of Healthcare Providers and Systems

THA

total hip arthroplasty

HCHE

Hospital Commitment to Health Equity

TKA

total knee arthroplasty

HCP

healthcare personnel

UTI

urinary tract infection

HF

heart failure

VTE

venous thromboembolism

HH

Hospital Harm

VTE

venous thromboembolism