FY 2026 Mandatory Hybrid HWR and Hybrid HWM Measure Data Due October 1, 2024
For all hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program: the Hybrid Hospital-Wide All-Cause Readmission (HWR) measure and Hybrid Hospital-Wide All-Cause Risk Standardized Mortality (HWM) measure data submission deadline is Tuesday, October 1, 2024, at 11:59 p.m. Pacific Time.
The Centers for Medicare & Medicaid Services (CMS) requires subsection (d) hospitals that participate in the Hospital IQR Program use Certified Electronic Health Record Technology to submit data on Medicare Fee-for-Service patients aged 65 and older (between 65 and 94 years for the Hybrid HWM measure) at the start of an inpatient admission who are discharged from an inpatient admission during the measurement period (length of stay < 365 days) between July 1, 2023, and June 30, 2024. These data will impact the fiscal year 2026 payment determination and measure results will be publicly reported.
As currently finalized, hospitals must meet the following requirements:
- Submit all linking variables on 95% or more of discharges.
- Report all vital signs for 90% or more of the hospital discharges.
- Submit all laboratory test results for 90% or more of discharges for non-surgical patients, meaning those not included in the surgical specialty cohort of the Hybrid HWR measure or the surgical divisions of the Hybrid HWM measure.
We note that due to reporting challenges expressed by some providers, the CY 2025 Outpatient Prospective Payment System proposed rule includes a proposal to continue voluntary reporting of the core clinical data elements (CCDEs) and linking variables for both the Hybrid HWR and Hybrid HWM measures, for the performance period of July 1, 2023 through June 30, 2024, impacting the FY 2026 payment determination for the Hospital IQR Program. We encourage providers to submit comments on this proposal.
Extraordinary Circumstances Exceptions (ECE)
For circumstances relating to the reporting of hybrid measures, a hospital participating in the Hospital IQR Program that wishes to request an exception must submit its request to CMS within 90 calendar days from when you determined that the extraordinary even occurred. The event may occur during the measurement period through the submission or reporting deadline. Refer to the ECE Policy page on QualityNet.
Resources
More information on the Hybrid HWR and Hybrid HWM measures is available on the eCQI Resource Center and QualityNet websites. Visit the eCQM Archived Events page of QualityReportingCenter.com and the Hospital Quality Reporting (HQR) Support Video Playlist for videos that provide assistance on the data submission process.
Be sure to complete and submit the Hospital Contact Change Form to ensure we have the correct contact information for your facility in our system.
Contact Information
For questions about the implementation of the hybrid measures and related claim-based specifications, please submit a ticket to the CMS Quality Question and Answer Tool by selecting IQR – Inpatient Quality Reporting under Program and Hybrid Measures under Topic.
For questions regarding the measure logic, value sets and electronic specifications for the hybrid measures, please submit a ticket to the ONC JIRA tool.
For questions regarding the HQR System, including questions regarding user roles, reports, data upload, and troubleshooting file errors, please contact the Center for Clinical Standards and Quality Service Center at (866) 288-8912 or QNetSupport@cms.hhs.gov.
For further assistance regarding the Hospital IQR Program and policy information contained in this message, please contact the Inpatient & Outpatient Healthcare Quality Systems Development & Program Support Contractor. Or call them at (844) 472-4477.