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CMS HQR System Now Accepting CY 2022 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) 2022 reporting period. The HQR System has been updated to accept Quality Reporting Document Architecture (QRDA) Category I test and production files using CY 2022 requirements.

Note: 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 are provided by hospitals, or by health IT vendors on the hospital’s behalf, 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 2022 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 three self-selected quarters of CY 2022 data (Q1, Q2, Q3 or Q4) by the reporting deadline. Each self-selected 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 reporting deadline is Tuesday, February 28, 2023, 11:59 p.m. Pacific Time (PT). The successful reporting of CY 2022 eCQM data will apply towards the Hospital IQR and Medicare Promoting Interoperability Programs.

Successful submission of eCQM data includes any combination of QRDA Category I 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 (EHR) technology certified to report the eCQMs. Hospitals are required to use technology certified to the existing 2015 Edition criteria for Certified Electronic Health Record Technology (CEHRT), technology certified to the 2015 Edition Cures Update criteria, or a combination of the two to meet the definition. CY 2022 program requirements are posted on the QualityNet and CMS.gov websites.

Note: The Medicare Promoting Interoperability Program requirements and attestation deadline for eligible hospitals and critical access hospitals is Tuesday, February 28, 2023, 11:59 p.m. PT.

Where are the technical materials for reporting eCQMs for the CY 2022 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 2022 QRDA Category I Implementation Guide (IG), Schematron and sample files, eCQM specifications, eCQM Flows, and the eCQM value set addendum. In addition, the Measure Collaboration Workspace offers the eCQM Data Element Repository for users who need additional clarification regarding definitions and clinical focus for all eCQM specification data elements.

Where can I learn about changes to the CY 2022 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 2024 eCQM and Hybrid HWR Measure Data webinar. Slides 30–39 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 2022 eCQM data submission process?

Resources and tools for CY 2022 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:

Contact Information
  • For further assistance regarding the Hospital IQR Program and policy information contained in this message, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at https://cmsqualitysupport.servicenowservices.com/qnet_qa or (844) 472-4477.
  • Questions regarding any aspect of the attestation process and the Medicare Promoting Interoperability Program can be directed to the CCSQ Service Center at QNetSupport@cms.hhs.gov or (866) 288-8912. The CCSQ Service Center can also assist with questions regarding the HQR System, which includes user roles, reports, data upload, and troubleshooting file errors.
  • For questions regarding eCQM specifications, value sets, and appropriateness of mapping, please submit questions to the Office of the National Coordinator for Health Information Technology (ONC) eCQM Issue Tracker at https://oncprojectracking.healthit.gov/support/projects/CQM/summary.

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Last Updated: May 24, 2023