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Small hospitals and CAHs are not required to submit eCQMs but may do so if they choose in order to meet their minimum reporting requirements. For CY2021: Those electing to submit eCQMs in order to meet their minimum reporting requirements must submit two quarters of data for any eCQM measure they choose to submit. For CY2022: Those electing to submit eCQMs in order to meet their minimum reporting requirements must submit three quarters of data for any eCQM measure they choose to submit. For CY2023: Those electing to submit eCQMs in order to meet their minimum reporting requirements must submit four (all) quarters of data for any eCQM measure they choose to submit. |
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Small hospitals and CAHs are not required to collect data on the PC chart-abstracted measures to meet their ORYX reporting requirements. However, those facilities providing obstetrical services may elect to use any of the PC measures (chart-abstracted and/or eCQMs) to meet their reporting requirement if they provide obstetrical services. |
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For CY2021: Any facility electing or required to submit eCQMs must submit a minimum of two (2) quarters of eCQM data. For CY2022: Any facility electing or required to submit eCQMs must submit a minimum of three (3) quarters of eCQM data. For CY2023: Any facility electing or required to submit eCQMs must submit all four (4) quarters of eCQM data. |
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SPECIALTY HOSPITALS |
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For Joint Commission purposes, accredited general medical/surgical hospitals with inpatient psychiatric units or operate a separate psychiatric hospital surveyed and accredited under the main Joint Commission accredited hospital are not required to report on the HBIPS measures, however, may do so if they choose. The CMS Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program includes inpatient psychiatric facilities and inpatient psychiatric units that bill under the Medicare Inpatient Psychiatric Facilities Prospective Payment System. NOTE: For Joint Commission reporting purposes, when determining the patient population to be included and sampled (using Global Sampling specifications), all applicable inpatients from across the accredited hospital must be included regardless of location, setting of care, and/or payment source. Hospitals submitting HBIPS must implement the Joint Commission’s sampling requirements. CMS accepts the Joint Commission’s sampling requirements for their Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program |
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