Applicability of Quality Reporting Requirements for Acute Care Hospitals, PCHs, SNFs, HHAs, Hospices, IRFs, LTCHs, ASCs, Renal Dialysis Facilities, and MIPS Eligible Clinicians Affected by California Wildfires

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions* under certain Medicare quality reporting and value-based purchasing and payment programs to acute care hospitals, Prospective Payment System (PPS)-exempt cancer hospitals, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, renal dialysis facilities, long- term care hospitals, and ambulatory surgical centers, as well as Merit-based Incentive Payment System (MIPS) eligible clinicians, located in areas affected by the California wildfires due to the devastating impact of the fires. These healthcare providers and suppliers will be granted exceptions without submitting a request if they are located in one of the California counties listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster county.

The scope and duration of the exception under each Medicare quality reporting program and value-based purchasing and payment program are described below. CMS is granting exceptions to assist these healthcare providers while they direct their resources toward caring for their patients and repairing structural damages to facilities. Facilities that are able to, and choose to do so, may submit their data and continue participation in the program.

CMS is closely monitoring the situation for future potential widespread catastrophic events, and will update exception lists soon after any events occur in the future.

The affected California counties designated by FEMA under the California Wildfires (DR-4407) as of the date of this communication, are as follows:

• Butte
• Los Angeles
• Ventura

The healthcare providers located outside of the counties listed above are not covered by this communication but may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing and payment programs they participate in using the applicable extraordinary circumstances exception procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.

If FEMA expands the current disaster declaration for the California wildfires to include additional counties, CMS will update this communication to reflect the expanded list of applicable counties for which healthcare providers would be eligible to receive an exception without submitting a request. In addition, CMS will continue to monitor the situation and adjust exempted reporting periods and submission deadlines accordingly.

Home Health Agencies (HHAs), Hospices, Inpatient Rehabilitation Facilities (IRFs), Long- Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs)

CMS is granting an exception to all Quality Reporting Program (QRP) reporting requirements, including the reporting of data on measures and any other data requested by CMS for the post- acute care (PAC) QRPs. See below for specific quarters for each PAC setting.

• HHAs – Home Health QRP  Quarter 4 (October 1, 2018 to December 31, 2018)
• Hospices – Hospice QRP Quarter 4 (October 1, 2018 to December 31, 2018)
• IRFs – Inpatient Rehabilitation Facility QRP Quarter 2 (April 1, 2018 to June 30, 2018) and Quarter 4 (October 1, 2018 to December 31, 2018)
• LTCHs – Long-Term Care Hospital QRP Quarter 2 (April 1, 2018 to June 30, 2018) and Quarter 4 (October 1, 2018 to December 31, 2018)
• SNFs – Skilled Nursing Facility QRP Quarter 2 (April 1, 2018 to June 30, 2018) and Quarter 4 (October 1, 2018 to December 31, 2018)

PAC QRP Extraordinary Circumstances Exception Request Information

For further information about exceptions, view the program-specific web pages:

• Home Health Quality Reporting Reconsideration and Exception & Extension or email questions to HHAPUReconsiderations@CMS.hhs.gov
• Hospice Quality Reporting Extensions and Exemption Requests or email questions to HospiceQRPReconsiderations@cms.hhs.gov
• IRF Quality Reporting Reconsideration and Exception & Extension or email questions to IRFQRPReconsiderations@cms.hhs.gov
• LTCH Quality Reporting Reconsideration and Exception & Extension or email questions to LTCHQRPReconsiderations@cms.hhs.gov
• SNF Quality Reporting Reconsideration and Exception & Extension or email questions to SNFQRPReconsiderations@cms.hhs.gov

Hospitals - Inpatient Services

CMS is granting an exception to subsection (d) hospitals located in designated counties for the following reporting requirements under the Hospital Inpatient Quality Reporting (IQR) Program.

For the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey:

• January 2019 HCAHPS submission deadline for reporting period:
  • July 1, 2018 – September 30, 2018 (3rd Quarter 2018)

For the Influenza Vaccination Coverage Among Healthcare Personnel (HCP) measure:

• May 15, 2019 submission deadline for the 2018 – 2019 flu season:
  • October 1, 2018 – March 31, 2019 (4th Quarter 2018 through 1st Quarter 2019)

For all Hospital IQR Program chart-abstracted measures, including clinical population and sampling data and National Healthcare Safety Network (NHSN) Healthcare-Associated Infection (HAI) measures:

• Median Time from ED Arrival to ED Departure for Admitted ED Patients (ED-1)
• Admit Decision Time to ED Departure Time for Admitted Patients (ED-2)
• Influenza Immunization (IMM-2)
• Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) (SEP-1)
• Incidence of Potentially Preventable Venous Thromboembolism (VTE-6)
• Elective Delivery Prior to 39 Completed Weeks Gestation (PC-01)
• Central Line-Associated Bloodstream Infection (CLABSI) Outcome Measure
• Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure
• American College of Surgeons-Centers for Disease Control and Prevention Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Measure
• Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus
• (MRSA) Bacteremia Outcome Measure

• Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure:
  • November 2018 and February 2019 submission deadlines for reporting periods:
  • April 1, 2018 – June 30, 2018 (2nd Quarter  2018)
  • July 1, 2018 – September 30, 2018 (3rd Quarter  2018)

CMS is also granting an exception to affected subsection (d) hospitals for certain validation requirements, specifically Clinical Data Abstraction Center (CDAC) records for chart-abstracted measures and HAI validation templates. For Hospital IQR Program chart-abstracted measures data validation, medical records are normally due to the CDAC within 30 days of the date identified on the written request letter. Hospitals in designated counties are excepted from validation requirements as follows:

• CDAC record requests for reporting periods:
• April 1, 2018 – June 30, 2018 (2nd Quarter 2018)
• July 1, 2018 – October 31, 2018 (3rd Quarter 2018)
• HAI Validation Template February 1, 2018 submission deadline for reporting period:
• July 1, 2018 – October 31, 2018 (3rd Quarter 2018)

NOTE: Hospitals located within the designated counties listed above should be aware of the potential subsequent impact to the Hospital Value-Based Purchasing (VBP) Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Condition (HAC) Reduction Program Fiscal Year 2020 minimum case threshold counts that must be met in order to receive scores in these programs.

PPS-Exempt Cancer Hospitals

CMS is granting an exception to PPS-exempt cancer hospitals located in the counties described above for the following reporting requirements under the PPS-Exempt Cancer Hospital Quality Reporting Program.

For chart-abstracted data and NHSN HAI data:

• November 2018 and February 2019 submission deadlines for reporting periods:
  • July 1, 2017 – September 30, 2017 (3rd Quarter 2017) – Adjuvant Hormonal Therapy
  • October 1, 2017 – December 31, 2017 (4th Quarter 2017) – Adjuvant Hormonal Therapy
  • April 1, 2018 – June 30, 2018 (2nd Quarter 2018) – CLABSI, CAUTI, SSI, MRSA, CDI
  • July 1, 2018 – September 31, 2018 (3rd Quarter 2018) – CLABSI, CAUTI, SSI, MRSA, CDI

For the HCAHPS Survey:

• January 2019 HCAHPS submission deadline for reporting period:
  • July 1, 2018 – September 30, 2018 (3rd Quarter 2018)

For the Influenza Vaccination Coverage Among Healthcare Personnel (HCP) measure:

• May 15, 2019 submission deadline for the 2018 – 2019 flu season:
  • October 1, 2018 – March 31, 2019 (4th Quarter 2018 through 1st Quarter 2019)

Hospitals - Outpatient Services

CMS is granting an exception to subsection (d) hospitals located in the counties described above for the following reporting requirements under the Hospital Outpatient Quality Reporting (OQR) Program.

We note that CMS recently removed the Influenza Vaccination Coverage Among Healthcare Personnel (HCP) measure beginning with the CY 2020 payment determination (CY 2018 reporting period). For all Hospital OQR Program chart-abstracted measures:

• February 2019 and May 2019 submission deadlines for reporting periods:
  • July 1, 2018 – September 30, 2018 (3rd Quarter 2018)
  • October 1, 2018 – December 31, 2018 (4th  Quarter 2018)

For Hospital OQR Program chart-abstracted data validation, medical records are normally due to the CDAC within 45 days of the date identified on the written request letter. CMS is also granting an exception to affected subsection (d) hospitals for certain validation requirements as follows:

• CDAC record requests for reporting periods:
  • April 1, 2018 – June 30, 2018 (2nd Quarter 2018)
  • July 1, 2018 – September 30, 2018 (3rd Quarter 2018)

Ambulatory Surgical Centers (ASCs)

CMS is granting an exception to ASCs located in the counties described above for the following reporting requirements under the Ambulatory Surgical Center Quality Reporting (ASCQR) Program:

• Data collection and submission requirements that apply for all measures during the annual submission period of January 1, 2018 through December 31, 2018. These exceptions apply to measures submitted via the QualityNet Secure Portal web-based tool, including claims-based measures calculated from submitted Quality Data Codes (QDCs). This exception does not apply, however, to claims-based measures that do not utilize QDCs for calculation purposes. We note that CMS recently removed the Influenza Vaccination Coverage Among Healthcare Personnel (HCP) measure beginning with the CY 2020 payment determination (CY 2018 reporting period).

Hospital IQR, OQR, and ASCQR ECE Request Process

Hospitals and ASCs in counties and states outside of the designated areas may submit ECE requests based on individual circumstances by one of the following methods:

• Secure File Transfer via QualityNet Secure Portal, “WAIVER EXCEPTION WITHHOLDING” group
• E-mail to QRSupport@hcqis.org
• Secure fax to (877) 789-4443
• Mail to HSAG, Attention: Quality Reporting Support Contractor, 3000 Bayport Drive, Suite 300, Tampa, FL 33607

Please refer to the ECE Request process and form specific to the program of interest located on QualityNet for additional information.

• Hospital IQR Program: Select “Hospital Inpatient Quality Reporting Program” from the [Hospitals – Inpatient] tab drop-down list, followed by selecting the “Extraordinary Circumstances Form” link in the left side navigation bar: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228762258913.
  • The National Support Team for the Hospital IQR Program is available to answer questions or supply any additional information you may need. Please contact the team at inpatientsupport@viqrc1.hcqis.org or call toll-free at (844) 472-4477. 
• ASCQR Program: Select “Ambulatory Surgical Center (ASC) Program” from the [Ambulatory Surgical Centers] tab drop-down list, followed by selecting the “Extraordinary Circumstances Form” link in the left side navigation bar: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228772757396. See the next section under the Hospital OQR Program for contact information for ASCQR Program-related issues.
• Hospital OQR Program: Select “Hospital Outpatient Quality Reporting Program” from the [Hospitals – Outpatient] tab drop-down list, followed by selecting the “Extraordinary Circumstances Form” link in the left side navigation bar: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1192804531069.

• The National Support Team for both the Hospital OQR and ASCQR Programs is available to answer questions or supply any additional information you may need. Please contact the team at oqrsupport@hsag.com or qrsupport@hcqis.org or call toll- free at (866) 800-8756.

For questions regarding technical issues, contact the QualityNet Help Desk at the following email address: qnetsupport@hcqis.org.

MIPS Eligible Clinicians

On November 1, 2018, CMS released the CY 2019 Physician Fee Schedule final rule, which established an automatic extreme and uncontrollable circumstance policy for MIPS beginning with the 2018 performance period/2020 payment year, which applies to MIPS eligible clinicians affected by triggering events that affect an entire region or locale, including the California wildfires. Given the FEMA designation, we consider the California wildfires to be such a triggering event, and the automatic extreme and uncontrollable circumstance policy therefore applies to the California counties listed above as well. MIPS eligible clinicians who are subject to the Alternative Payment Model (APM) scoring standard are not covered by the automatic extreme and uncontrollable circumstance policy. However, a MIPS eligible clinician who is subject to the APM scoring standard and who has been affected by an extreme and uncontrollable circumstance may apply for an exception in the Promoting Interoperability performance category.

The data submission period for the 2018 performance period is January 2, 2019‒April 2, 2019. MIPS eligible clinicians in FEMA-designated areas affected by the California wildfires will be automatically identified, and no action is required. However, if you submit data for two or three performance categories (Quality, Improvement Activities, and/or Promoting Interoperability), you will be scored on the performance categories for which you submitted data. Your payment adjustment will be determined by your final score. Under the automatic extreme and uncontrollable circumstances policy, the Cost performance category will always be weighted at 0% and will not affect your final score, even if you submit data for the other performance categories.

MIPS Extreme and Uncontrollable Circumstances Exception Information

For more information on all exceptions (including those requiring an application), please reference the Extreme and Uncontrollable Circumstances Overview section on the MIPS >About Exception Applications page. You can also contact the Quality Payment Program Service Center at (866) 288-8292/TTY (877) 715-6222, Monday through Friday, 8:00 a.m. ‒ 8:00 p.m. Eastern Time or by email at qpp@cms.hhs.gov.

Circumstances Under Which an Exception Due to California Wildfires Must Be Requested in Order to Be Considered by CMS

Hospital VBP Program, HAC Reduction Program, End-Stage Renal Disease Quality Incentive Program (ESRD QIP), Hospital Readmissions Reduction Program, and Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)

Hospitals, renal dialysis facilities, and SNFs, regardless of location, may request an exception to reporting requirements under the Hospital VBP Program, HAC Reduction Program, Hospital Readmissions Reduction Program, and SNF VBP. CMS will assess, based on the request and

supporting evidence presented, whether and the degree to the extraordinary circumstance affected performance under the applicable program, such as whether a hospital’s readmission rate significantly increased as a result of having admitted patients who were evacuated from flooded facilities.

SNF VBP ECE Request Process

SNFs may submit ECE requests based on individual circumstances by emailing the following information to the snfvbpinquiries@cms.hhs.gov mailbox within 90 calendar days of the extraordinary circumstance:

• Facility Name and CMS Certification Number (CCN)
• Date of the extraordinary circumstance
• Justification/rationale for requesting ECE
• Supporting documentation of the extraordinary circumstance

ESRD QIP ECE Request Process

Facilities impacted by California wildfires may submit an ECE request form. If approved, the ECE exempts the facility from reporting requirements for an established period of time.

Organizations that own and operate multiple renal dialysis facilities may submit a request that includes, for each affected facility, the facility’s CCN and other required information. Please refer to the ECE request process and ECE request form located on QualityNet for additional information. This form must be submitted within 90 days of the extraordinary circumstances event.

For further assistance regarding the ESRD QIP information contained in this message, please contact the ESRD QIP at esrdqip@cms.hhs.gov.