Extraordinary Circumstance Exceptions and Measure Suppressions

Extraordinary Circumstance Exceptions
The purpose of this communication is to remind hospitals that the Centers for Medicare & Medicaid Services (CMS) offers a process for hospitals or facilities to request exceptions to the reporting of required quality data—including data for electronic clinical quality measures (eCQMs) —for one or more quarters when a provider experiences an extraordinary circumstance beyond their control. This communication is informational only and no action is needed.

Non-eCQM ECE Requests

Hospitals may request an exception with respect to quality data reporting requirements in the event of extraordinary circumstances beyond their control. Such circumstances may include, but are not limited to, natural disasters (such as a severe hurricane or flood) or systemic problems with CMS data-collection systems that directly affected the ability of the hospital to submit data.

For non-eCQM ECEs, hospitals must submit a CMS Quality Program Extraordinary Circumstances Exceptions (ECE) Request Form with all required fields completed within 90 calendar days of the extraordinary circumstance.

eCQM ECE Requests

Hospitals may use the same ECE request form to request an exception from the Hospital Inpatient Quality Reporting (IQR) Program’s eCQM reporting requirement for the applicable program year, based on hardships that prevented the hospital from electronically reporting. Such circumstances could include, but are not limited to, infrastructure challenges (e.g., a hospital is in an area without sufficient Internet access or unforeseen circumstances such as vendor issues outside of the hospital’s control, including a vendor product losing certification).

For eCQM ECE requests only, hospitals must submit an ECE request form, including supporting documentation, by April 1, following the end of the reporting period calendar year. As an example, for data collected for the calendar year 2022 reporting period (through December 31, 2022), hospitals would have until April 1, 2023, to submit an eCQM ECE request.

Performance-Related ECE Requests

For events adversely impacting your performance, for the Hospital Value-Based Purchasing (VBP) Program, Hospital Readmissions Reduction Program (HRRP), and Hospital-Acquired Condition (HAC) Reduction Program, the ECE must be submitted within 90 days of the date of the extraordinary circumstance. At the latest, ECEs should be submitted no later than 90 days from the last date of the quarter requested. For example, the last day of Q4 2021 was December 31, 2021. The ECE should be submitted no later than 90 days after the end of Q4, which would be March 31, 2022.

CMS will assess and decide upon each extraordinary circumstance’s exception request on a case-by-case basis.

Hospitals should be aware of the potential impact to reporting requirements and payment programs when deciding whether to report data included in the exceptions. Submitted data may be publicly reported or used in scoring.

Promoting Interoperability Hardship Requests

Eligible hospitals and Critical Access Hospitals (CAHs) can apply for a hardship exception and may be exempt from the Medicare downward payment adjustment if they can show that compliance with the requirement for being a meaningful electronic health record (EHR) user would result in a significant hardship.

If approved, the hardship exception is valid for only one payment adjustment year. Eligible hospitals and CAHs would need to submit a new application for subsequent years and no eligible hospital or CAH can be granted an exception for more than five years. The application period for performance year 2020 closed on September 1, 2021.

Please refer to the ECE request process and form specific to your program for additional information.   

Measure Suppressions

In the Fiscal Year (FY) 2022 Inpatient Prospective Payment System/Long-Term Care Hospital Prospective Payment System Final Rule, CMS adopted a measure suppression policy for the value-based and performance programs, for the duration of the Public Health Emergency for COVID-19. A summary of program-specific changes and applicable program years is detailed below.

For assistance regarding the information contained in this message, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Team at https://cmsqualitysupport.servicenowservices.com/qnet_qa, or (844) 472-4477. For questions regarding technical issues, contact the QualityNet Service Center at qnetsupport@hcqis.org