August 25, 2021

Today’s alert will act to continue our summarization of the 2022 Inpatient Prospective Payment System (IPPS) Final Rule (FR), which we began last week. The current summary will focus primarily on the new quality reporting requirements and is based in large measure on a synopsis of the FR provided by the Centers for Medicare and Medicaid Services (CMS).

Inpatient Quality-Reporting Program

The Hospital Inpatient Quality-Reporting (IQR) Program is a pay-for-reporting quality program that reduces payment to hospitals that fail to meet program requirements. Hospitals that do not submit quality data or fail to meet all Hospital IQR Program requirements are subject to a one-fourth reduction in their annual payment update under the IPPS. In the FY 2022 IPPS FR, CMS is adopting new measures, removing existing measures, and finalizing changes to existing EHR certification requirements along with other administrative updates.

Specifically, the rule finalizes the adoption of:

A new Maternal Morbidity Structural Measure, which will assess hospital participation in a statewide or national perinatal Quality Improvement initiative and implementation of safety practices or bundles. This measure will encourage hospitals to standardize protocols addressing obstetric emergencies and complications arising during pregnancy and childbirth, beginning with a shortened CY 2021 reporting period/FY 2023 payment determination;

The COVID-19 Vaccination Coverage Among Health Care Personnel measure, which will be reported to the CDC’s National Healthcare Safety Network web-based surveillance system, beginning with a shortened reporting period from October 1, 2021 through December 31, 2021, affecting the CY 2021 reporting period/FY 2023 payment determination and for subsequent years;

The Hybrid Hospital-Wide All-Cause Risk Standardized Mortality measure, beginning with a voluntary reporting period which will run from July 1, 2022 through June 30, 2023, and followed by mandatory reporting beginning with the reporting period which runs July 1, 2023 through June 30, 2024, affecting the FY 2026 payment determination and for subsequent years;

Two medication-related adverse event electronic clinical quality measures (eCQMs) (Hospital Harm-Severe Hypoglycemia eCQM (NQF #3503e) and Hospital Harm-Severe Hyperglycemia eCQM (NQF #3533e)) beginning with the CY 2023 reporting period/FY 2025 payment determination.
In addition, the rule finalizes the removal of:

The Exclusive Breast Milk Feeding (NQF #0480) beginning with the CY 2024 reporting period/FY 2026 payment determination. While this continues to be an important topic, CMS is finalizing the removal of this measure because of the availability of a measure that is more strongly associated with patient outcomes. Specifically, in keeping with the agency’s focus on maternal health, CMS is finalizing the adoption of the Maternal Morbidity Structural Measure;

The Admit Decision Time to Emergency Department (ED) Departure Time for Admitted Patients (NQF #0497) beginning with the CY 2024 reporting period/FY 2026 payment determination. CMS is finalizing the removal of this measure because the costs associated with the measure outweigh the benefit of its continued use in the program;

Discharged on Statin Medication eCQM (STK-06) (NQF #0439), beginning with the CY 2024 reporting period/FY 2026 payment determination. While CMS continues to believe that ensuring appropriate pharmacotherapy for stroke patients is an important topic, within the Hospital IQR Program portfolio of stroke measures, CMS identified STK-06 as appropriate for removal.
CMS is not finalizing proposals to remove the Anticoagulation Therapy for Atrial Fibrillation/Flutter eCQM (STK-03) or the Death Rate Among Surgical Inpatients with Serious Treatable Complications (PSI-04) measure after considering the stakeholder feedback received.

Additionally, beginning with the CY 2023 reporting period/FY 2025 payment determination, CMS is finalizing the requirement for hospitals to use certified EHR technology that has been updated consistent with the 2015 Edition Cures Update and is clarifying that certified technology must support the reporting requirements for all available eCQMs.

Medicare Promoting Interoperability Program

In 2011, CMS established the Medicare and Medicaid EHR Incentive Programs (now known as the Medicare and Medicaid Promoting Interoperability Programs) to encourage eligible professionals, eligible hospitals, and critical access hospitals (CAHs) to adopt, implement, upgrade, and demonstrate meaningful use of certified EHR technology (CEHRT). Under 1903(t)(5)(D) of the Social Security Act, December 31, 2021 is the last date that States can make Medicaid Promoting Interoperability payments to Medicaid eligible hospitals (other than pursuant to a successful appeal related to CY 2021 or a prior year).

CMS is finalizing the following changes to the Medicare Promoting Interoperability Program for eligible hospitals and CAHs:

Continue the EHR reporting period of a minimum of any continuous 90-day period for new and returning eligible hospitals and CAHs for CY 2023 and to increase the EHR reporting period to a minimum of any continuous 180-day period for new and returning eligible hospitals and CAHs for CY 2024;

Maintain the Electronic Prescribing Objective’s Query of Prescription Drug Monitoring Program (PDMP) measure as optional while increasing its available bonus from 5 points to 10 points;

Add a new Health Information Exchange (HIE) Bi-Directional Exchange measure as a yes/no attestation, beginning in CY 2022 to the HIE objective as an optional alternative to the two existing measures;

Require reporting “yes” on four of the existing Public Health and Clinical Data Exchange Objective measures (Syndromic Surveillance Reporting, Immunization Registry Reporting, Electronic Case Reporting, and Electronic Reportable Laboratory Result Reporting) or requesting applicable exclusion(s);

Attest to having completed an annual assessment of all nine guides in the SAFER Guides measure, under the Protect Patient Health Information objective;

Remove attestation statements 2 and 3 from the Promoting Interoperability Program’s prevention of information blocking attestation requirement;

Increase the minimum required scoring threshold for the objectives and measures from 50 points to 60 points (out of 100 points) to be considered a meaningful EHR user; and

Adopt two new eCQMs to the Medicare Promoting Interoperability Program’s eCQM measure set beginning with the reporting period in CY 2023, in addition to removing three eCQMs from the measure set beginning with the reporting period in CY 2024 (in alignment with proposals for the Hospital IQR Program).
We will provide one final installment of the 2022 IPPS Final Rule summary next week. Until then, if you wish to contact us, please go to info@miramedgs.com.