There were really no surprises given all the efforts going into COVID-19 management, but organizations’ quality departments do need to be watchful of the following proposed implications.

  • Public reporting of eCQM data – yes CMS is finally going to make eCQMs public, so have you looked at your data lately?
  • Reporting an increased number of calendar quarters for eCQM submissions – be ready to coordinate with your vendor to have those QRDA I files.
  • Submitting electronic files of medical records for the validation process – no more paper, CD, DVD, or flash drive formats. It’s time for electronic submission format capabilities.
  • Transitioning to a combined chart-abstracted and eCQM validation process – those eCQMs are starting to really be put to the test.
  • Reporting for the Hybrid HWR measure – it is not going away and you may be challenged in capturing the right values from the EHR.

In this blog, we provide a summary of proposed quality reporting updates for the hospital Medicare and Medicaid Promoting Interoperability (PI) programs and the Medicare Inpatient Quality Reporting (IQR) program. Our focus is on reporting requirements for the PI objective measures and electronic clinical quality measures (eCQMs). Content is based on the fiscal year (FY) 2021 inpatient prospective payment system (IPPS) proposed rule with insights from emids subject matter experts.

Along with this blog, we have developed an InfoAlert that provides more details and implications that can be of value as you prepare for the 2021 reporting year.

About the FY 2021 IPPS Proposed Rule

On May 11, 2020, the Centers for Medicare and Medicaid Services (CMS) filed a proposed rule titled: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2021 Rates; Quality Reporting and Medicare and Medicaid Promoting Interoperability Programs Requirements for Eligible Hospitals and Critical Access Hospitals. The Federal Register publish date is May 29, 2020. Comments are due on July 10, 2020.  We refer to this rule as the FY 2021 IPPS Proposed Rule.

The final rule is expected to be published 30 days prior to its effective date, which is Fiscal Year October 1, 2020. Due to the COVID-19 public health emergency, CMS is waiving the 60-day delay and expects to provide a 30-day delay in the effective date of the FY 2021 IPPS final rule. That means we can expect to see the final rule published in September rather than August.

Requirements for PI and IQR Programs

As CMS looks toward the future of the Promoting Interoperability Program, the general goals include reducing administrative burden, supporting alignment with the Quality Payment Program and the 21st Century Cures Act, advancing interoperability and the exchange of health information, and promoting innovative uses of health IT. Although there are not a lot of new requirements proposed in this rule, CMS is holding true to gradually increasing the use of electronic quality reporting and aligning requirements within the IQR and the PI programs.

Key Areas of Interest

The most significant quality reporting proposals in this rule are for eCQMs. For the PI and IQR program, the proposals involve a yearly increase in number of quarters for eCQM reporting and the readiness to publicly report eCQM data. There is also the proposal to integrate the validation processes for chart-abstracted measures and eCQMs. Additionally, there are proposed minor modifications to the PI Program objective measures. Finally, for the IQR program, CMS is proposing certified EHR technology (CEHRT) requirements for the hybrid measures.

CMS’ proposals for the Medicare PI program

  • Electronic Prescribing Objective measure: Query of Prescription Drug Monitoring Program (PDMP). CMS will continue counting the e-Prescribing Query of PDMP measure as optional for the CY 2021 reporting year; it would be worth 5 bonus points.
  • Health Information Exchange (HIE) measure: Support Electronic Referral Loops by Receiving and Incorporating Health Information. CMS is proposing to change the name of the HIE 2 measure to: Support Electronic Referral Loops by Receiving and Reconciling Health Information. As a reminder, there is no exclusion for this measure.

CMS’ proposals for the Medicare PI program and the IQR Program

  • Number of eCQM reporting quarters. Progressively increase the number of quarters for hospitals to report eCQM data over a 3-year period.
    • CY 2020 reporting year: 1 self-selected calendar quarter of data
    • CY 2021 reporting year: 2 self-selected calendar quarters of data
    • CY 2022 reporting year: 3 self-selected calendar quarters of data
    • CY 2023 reporting year: 4 self-selected calendar quarters of data
  • Public reporting of eCQM data. CMS is proposing to begin publicly reporting eCQM performance data as early as the Fall of 2022 based on the CY 2021 reporting year data.
  • Validation Process. CMS is proposing to streamline the validation process beginning with FY 2022 Reporting Year / FY 2024 Payment Determination.
    • Chart abstraction would require use of electronic file submissions via a CMS-approved secure file transmission process.
    • Combine the chart-abstracted measures and eCQMs:
      • align data submission quarters
      • combine hospital selection (reduce the pool of hospitals randomly selected for chart-abstracted measures)
      • integrate and apply targeting criteria for eCQM validation
      • remove previous exclusion criteria
      • provide one combined validation score for chart-abstracted measures and eCQMs (eCQMs score weighted at zero)
      • formalize process for conducting educational reviews

CMS’ proposal for the Hospital IQR Program

  • Hybrid Measures. Beginning with FY 2026 Payment Determination, CMS is proposing to continue the policy that requires hospitals to use EHR technology certified to the 2015 Edition to submit data on the Hybrid Hospital-wide Readmission (HWR) with Claims measure. Additionally, they are proposing to expand this requirement to any future hybrid measures adopted into the Hospital IQR Program’s measure set. The core clinical data elements and linking variables must be submitted using the Quality Reporting Document Architecture (QRDA) I file format for the Hybrid HWR measure and future hybrid measures in the program.

So, what does this all mean?

As stated in the beginning, there are no big changes but below are some potential implications to consider in planning for the proposed quality reporting updates.

  • eCQM Reporting Periods. The proposed increase in number of reporting periods will require a higher level of coordination with vendors to provide timely QRDA I reports.
  • eCQM Public Reporting. Public reporting of eCQM data will require additional eCQM data review time and potential updates to the processes for monitoring and managing quality data outcomes to ensure the right data elements are captured.
  • Query of PDMP Measure. If an organization has gotten validation from their vendor that they have the ability to integrate a PDMP query through the CEHRT, then it’s important for the organization to ask the vendor if they can produce a report that shows how many times someone provided a query through the CEHRT. This will be required as supporting evidence in case of an audit.
  • Chart-abstraction CQM Validation Process. Organizations need to be prepared for when CMS provides the approved file transmission process (secure ftp) ensuring they have a way to create an electronic document, such as a PDF.
  • Hybrid Measures Core Clinical Data Elements. Even though the Hybrid measure is not classified as an eCQM, the effort to map, extract and validate core clinical data elements from the EHR will be similar to eCQMs. As an example, hospitals over the years have added more values for labs and vital signs since the original EHR build, causing challenges in capturing all the right values when mapping the Hybrid measure. This takes some time and testing, which is one reason why CMS is giving hospitals the additional two years to address potential data collection issues before mandatory reporting is required.

emids has developed an InfoAlert that provides more detail regarding the PI and IQR programs within this proposed rule that can affect your organization. Click on this link to download our detailed InfoAlert.


Collaboration of content for this blog was provided by emids subject matter experts in the Provider Business Unit, covering important quality reporting topics for our customers and partners. Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time. For more information about these proposed changes, contact us at