The Hospital Quality Reporting System Now Accepting Voluntary Hybrid Measures for the 2024 Reporting Period

The Hospital Quality Reporting (HQR) System is now open for the voluntary submission of fiscal year (FY) 2025 Hybrid Hospital-Wide All-Cause Readmission (HWR) measure and/or the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality (HWM) measure data for the July 1, 2022, through June 30, 2023, reporting period. The Centers for Medicare & Medicaid Services (CMS) has updated the HQR System to accept Quality Reporting Document Architecture (QRDA) Category I test and production files that use the 2022 reporting period requirements. The requirements are located on the Electronic Clinical Quality Improvement Resource Center.

There is no impact to the 2025 payment dermination for hospitals that do not submit data on these measures during the voluntary period. These measure results will not be publicly reported. Subsection (d) hospitals in the Hospital Inpatient Quality Reporting (IQR) Program may voluntarily submit these data.

Note: Data submission for these measures will become mandatory for all subsection (d) hospitals participating in the Hospital IQR Program beginning with the July 1, 2023, through June 30, 2024, reporting period. These data will impact the FY 2026 payment determination and measure results will be publicly reported.

2024 Voluntary Reporting Hybrid HWR and/or Hybrid HWM Measure Details

CMS is asking subsection (d) hospitals that partipate in the Hospital IQR Program to voluntarily 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 and discharged from an inpatient admission at the hospital during the measurement period (length of stay <365 days) between July 1, 2022, and June 30, 2023. The data submission deadline is Monday, October 2, 2023, 11:59 p.m. Pacific Time.

Hospitals participating in the voluntary reporting process will:

• Use the most current guidance applicable to the 2022 reporting period.
• Use Certified Electronic Health Record Technology updated to meet 2015 Edition Cures Update criteria.
• Submit QRDA Category I files for each eligible hospital discharge, batched per patient and per quarter (one QRDA Category I file, per quarter, per patient, inclusive of the data that are relevant for either/both the Hybrid HWR and Hybrid HWM measures) to the HQR System.
• Receive a confidential Hospital-Specific Report in the spring of 2024.

More information on the Hybrid HWR and Hybrid HWM Measures is available on the Hybrid Measure page of the QualityNet website. On that page, you can also access the 2024 Key Resource and Dates document.

Preparing to Submit Hybrid HWR and/or Hybrid HWM Measure Data to the HQR System

All hospitals and vendors participating in the voluntary Hybrid HWR measure and/or the Hybrid HWM measure data submission process will need the necessary HQR user role permission and vendor access to view, upload, and edit their data.

Basic users with the eCQM permission will automatically receive the same level of access for the hybrid measures. New users will need to log in to HQR and request access for the eCQM permission to either view or upload/edit hybrid measure data. A new vendor authorization is required when a vendor submits hybrid measure data on the hospital's behalf: Hospitals will select Vendor Management and eCQM to add/edit permissions for hybrid measure data.

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 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 Value, Incentives, and Quality Reporting Outreach and Education Support Contractor or (844) 472-4477.