HQR System Now Accepting Voluntary Hybrid HWR Measure Data

The Hospital Quality Reporting (HQR) System is now open for the voluntary submission of fiscal year (FY) 2024 Hybrid Hospital-Wide Readmission (HWR) measure data for the July 1, 2021, through June 30, 2022, 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 2021 reporting period requirements. The requirements are located on the eCQI Resource Center.

Subsection (d) hospitals in the Hospital Inpatient Quality Reporting (IQR) Program may voluntarily submit these data. There is no impact to the FY 2024 payment determination of hospitals that do not submit these data.

Note: Starting with the 2025 mandatory reporting period, CMS will require subsection (d) hospitals participating in the Hospital IQR Program to report Hybrid HWR and Hybrid Hospital-Wide All-Cause Risk Standardized Mortality (HWM) measure data for the July 1, 2023 through June 30, 2024, reporting period. These data will impact the FY 2026 payment determination and will be publicly reported.

2023 Voluntary Reporting Hybrid HWR Measure Details

CMS is asking subsection (d) hospitals that participate in the Hospital IQR Program to voluntarily submit data on Medicare Fee-for-Service (FFS) patients aged 65 and older who were discharged between July 1, 2021, and June 30, 2022. The data submission deadline is Friday, September 30, 2022, 11:59 p.m. Pacific Time (PT).

As noted above, Hybrid HWR measure data that are voluntarily submitted for the 2023 reporting period will not affect the hospital’s annual payment update (APU) under the Hospital IQR Program. CMS will provide a confidential Hospital-Specific Report (HSR) to hospitals in spring of 2023. These measure results will not be publicly reported.

Hospitals participating in the voluntary reporting process should:

• Use the most current guidance applicable to the 2021 reporting period.
• 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 both.

• Submit one QRDA Category I file per patient, per quarter, containing 13 Core Clinical Data Elements (CCDE) and 6 linking variables for each eligible hospital discharge. Please reference the electronic specifications available on the eCQI Resource Center.

During the voluntary reporting period, hospitals should submit data according to the following Hospital IQR Program requirements:

• Submit linking variables on 95% or more of discharges with a Medicare FFS claim for the same hospitalization during the measurement period.
• Report vital signs for 90% or more of the hospital discharges for Medicare FFS patients, 65 years or older in the measurement period (as determined from the claims submitted to CMS for admissions that ended during the same reporting period).
• Submit the 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.

Additional information is posted on the Hybrid Measure page on the QualityNet website.

2023 Voluntary Reporting Hybrid HWR Measure Technical Materials

Hospitals may find information on the electronic specifications of the Hybrid HWR measure (CMS529v1) on the eCQI Resource Center. Other reference materials available for download include the following:

• An eCQM annual update implementation checklist
• Value sets and direct reference codes for the Hybrid HWR measure
• A 2023 Voluntary Reporting Key Dates and Resources document  
• The Calendar Year (CY) 2021 QRDA Category I Implementation Guide (IG), Schematron, and Sample Files for Hospital Quality Reporting

Updated claims-based specifications for the Hybrid HWR measure will be available on the QualityNet website in spring of 2023. Meanwhile, hospitals and vendors may review the Annual Updates and Specifications Report for the claims-only HWR measure methodology and the Hybrid HWR measure methodology.

Preparing to Submit Hybrid HWR Measure Data to the HQR System

All hospitals and vendors participating in the voluntary Hybrid HWR measure data submission process will need the necessary HQR user role permissions 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 HWR measure. New users will need to log into HQR and select Access Management to request the eCQM permission. A new vendor authorization is required when a vendor submits Hybrid HWR measure data on the hospital’s behalf: Hospitals will select Vendor Management and eCQM to add/edit permissions for Hybrid HWR measure data. Visit the HQR Support Video Playlist for additional assistance.

This summer, a webinar will demonstrate the voluntary Hybrid HWR measure data submission process via the HQR System. Listserve notifications will communicate the information to register for this webinar. You can also visit the Event Calendar of the Quality Reporting Center website for details.

Contact Information

• For questions about the implementation of the Hybrid HWR measure or its 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 electronic specifications of the Hybrid HWR measure and value sets, please submit a ticket to the JIRA tool: https://oncprojectracking.healthit.gov/support/projects/CHM/summary
• For questions regarding the HQR System, including questions regarding user roles, reports, data upload, and troubleshooting file errors, please contact the CCSQ 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 at https://cmsqualitysupport.servicenowservices.com/qnet_qa or (844) 472-4477.