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Quality Reporting Programs: Extension of Data Submission Deadlines in Response to COVID-19

Craneware® Insights Regulatory Updates – CWI1216 (26 March 2020)


Topic

Quality Reporting Programs: Extension of Data Submission Deadlines in Response to COVID-19

On March 22, 2020, CMS announced extensions for upcoming quality measure reporting and data submission deadlines.

Provider Types Affected

Critical Access Hospitals
OPPS Hospitals
Provider-Based FQHC
Provider-Based Rural Health Clinics
Physicians

Departments/Areas Affected

Business Office
Compliance / Revenue Integrity
Finance
HIM/Medical Records

What You Need to Know

CMS recognizes that quality measure reporting may not reflect performance for measures such as cost, readmissions and patient experience during the COVID-19 emergency. To that end, CMS is issuing policy exceptions and extensions for upcoming quality measure reporting and data submission for the following CMS programs:

Provider Programs 2019 Data Sbmission 2020 Data Submission
Quality Payment Program-Merit-based Incentive Payment System (MIPS) Deadline extended from March 31, 2020 to April 30, 2020 MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year. CMS is evaluating options for providing relief around participation and data submission for 2020.
Medicare Shared Savings Program Accountable Care Organizations (ACOs)
 
Hospital Programs 2019 Data Submission 2020 Data Submission
Ambulatory Surgical Center Quality Reporting Program Deadlines for October 1, 2019 – December 31, 2019 (Q4) data submission optional.   If Q4 is submitted, it will be used to calculate the 2019 performance and payment (where appropriate). If data for Q4 is unable to be submitted, the 2019 performance will be calculated based on data from January 1, 2019 – September 30, 2019 (Q1-Q3) and available data   CMS will not count data from January 1, 2020 – June 30, 2020 (Q1-Q2) for performance or payment programs. Data does not need to be submitted to CMS for this time period.   * For the Hospital-Acquired Condition Reduction Program and the Hospital Value-Based Purchasing Program, if data from January 1, 2020 – March 31, 2020 (Q1) is submitted, it will be used for scoring in the program (where appropriate).
Hospital-Acquired Condition Reduction Program
Hospital Inpatient Quality Reporting Program
Hospital Outpatient Quality Reporting Program
Hospital Readmissions Reduction Program
Hospital Value-Based Purchasing Program
PPS-Exempt Cancer Hospital Quality Reporting Program
Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals
ESRD Quality Reporting and Quality Incentive Programs

Facilities have the option whether or not to report data for programs with data submission deadlines in April and May 2020. CMS will not use data which reflects services provided from January 1, 2020 through June 30, 2020 in its calculations for Medicare Quality Reporting and value-based purchasing programs.

Action Needed

Hospitals/providers should inform staff who are responsible for data collection and submission for Medicare Quality Reporting and value-based purchasing programs of the temporary suspension of program-related deadlines. To stay up to date on the CMS actions in response to the COVID-19 crisis, we recommend frequently accessing the CMS Emergencies Webpage.

Effective Date

20 March 2020

Background

CMS Emergencies Webpage:

https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page

Reference

https://www.cms.gov/newsroom/press-releases/cms-announces-relief-clinicians-providers-hospitals-and-facilities-participating-quality-reporting

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