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CMS HQR System Now Accepting CY 2023 eCQM Data

The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals and vendors that the Hospital Quality Reporting (HQR) System is now accepting electronic clinical quality measure (eCQM) data for the calendar year (CY) 2023 reporting period. The HQR System now accepts Quality Reporting Document Architecture (QRDA) Category I test and production files using CY 2023 requirements.

Test QRDA Category I data submissions are considered practice submissions, and they do not count towards CMS program credit. Production QRDA Category I data submissions by hospitals, or by health IT vendors on the hospital’s behalf, count as final data submissions to fulfill the eCQM reporting requirements for the Hospital Inpatient Quality Reporting (IQR) and Medicare Promoting Interoperability Programs. 

What are the CY 2023 eCQM reporting requirements? 
Hospitals are required to submit data for the mandatory Safe Use of Opioids-Concurrent Prescribing eCQM and three self-selected eCQMs, for four quarters of CY 2023 data (Q1, Q2, Q3, and Q4) by the reporting deadline of Thursday, February 29, 2024, 11:59 p.m. Pacific Time (PT).

Each quarter must contain at least three self-selected eCQMs, plus the mandatory Safe Use of Opioids-Concurrent Prescribing eCQM. The eCQMs must be the same eCQMs across quarters in a given reporting year. The successful submission of CY 2023 eCQM data will apply towards the Hospital IQR and Medicare Promoting Interoperability Programs impacting the fiscal year (FY) 2025 payment determination for eligible hospitals and the FY 2023 payment determination for critical access hospitals.

Successful submission of eCQM data includes any combination of QRDA Category I production files with patients meeting the initial patient population of the applicable measure(s), zero denominator declarations, and/or case threshold exemptions. Use of the zero denominators and case threshold exemptions only apply if the hospital has electronic health record technology certified to report the eCQMs. Hospitals are required to use technology certified to the 2015 Edition Cures Update criteria. CY 2023 program requirements are posted on the QualityNet and websites. 

Note: The Medicare Promoting Interoperability Program requirements and attestation deadline for eligible hospitals and critical access hospitals is also Thursday, February 29, 2024, 11:59 p.m. PT


Where are the technical materials for reporting eCQMs for the CY 2023 reporting period? 
The Electronic Clinical Quality Improvement (eCQI) Resource Center is the one-stop shop for the most current resources to support electronic clinical quality improvement. Reference materials are available for download. They include an eCQM annual update implementation checklist, CY 2023 QRDA Category I Implementation Guide (IG), Schematron and sample files, eCQM specifications, eCQM Flows, and the eCQM value set addendum. 

Where can I learn about changes to the CY 2023 QRDA Category I IG for HQR and updates to the Health Level Seven (HL7) base standard? 
Visit the archived events page of the Quality Reporting Center website to review materials from the Resources for Reporting FY 2025 eCQM and Hybrid Measure Data webinar. Slides 29–48 outline IG changes, show document-level template changes, and provide a high-level overview of updates to the HL7 base standard. 

Where can I locate resources to assist with the CY 2023 eCQM data submission process?
Resources and tools for CY 2023 eCQM reporting are available for download from the QualityNet eCQM Resources web page and the eCQM Resources and Tools web page on the Quality Reporting Center website. The following tools are available:

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Last Updated: Sep 14, 2023