Centers for Medicare & Medicaid Services (CMS) Quality Improvement Program Measures for Acute Care Hospitals - Fiscal Year (FY) 2020 Payment Update

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1 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2020 Centers for Medicare & Medicaid Services (CMS) Improvement s for Acute Care s - Fiscal Year (FY) 2020 Payment Update IQR IQR Value- (VBP) VBP VBP - HAC HAC Compare Clinical Process of Care s (via Chart-Abstraction) ED-1 ED-2 for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients No No No No No No No No IMM-2 Influenza Immunization Note The IMM-2 measure is collected for all 4 quarters; however, only discharges included in 1st and 4th quarters will be included in the measure calculation. The IMM-2 measure is reported by flu season on CMS's Compare site Flu Season December Flu Season December 2019 No No No No PC-01 Elective Delivery 0469 Baseline Performance December 2019 No No No Sepsis Severe Sepsis and Septic Shock Management Bundle (Composite ) 0500 No No VTE-6 Incidence of Potentially Preventable Venous Thromboembolism EHR-Based Clinical Process of Care s ( Clinical s [ecqms]) No No No No AMI-8a Primary PCI Received Within 90 Minutes of Arrival * or Q4) TBD No ** CAC-3 Home Management Plan of Care Document Given to Patient/Caregiver * or Q4) TBD No ** ED-1 for Admitted ED Patients 0495 * or Q4) TBD No ** ED-2 Admit Decision Time to ED Departure Time for Admitted Patients 0497 * or Q4) TBD No ** ED-3 for Discharged ED Patients 0496 No No ** EHDI-1a Hearing Screening Prior to Discharge 1354 * or Q4) TBD No ** December

2 CMS s - Fiscal Year 2020 IQR IQR Value- (VBP) VBP VBP - HAC HAC Compare PC-01 Elective Delivery 0469 * or Q4) TBD No ** PC-05 Exclusive Breast Milk Feeding and the Subset PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice 0480 * or Q4) TBD No ** STK-02 Discharged on Antithrombotic Therapy 0435 * or Q4) TBD No ** STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter 0436 * or Q4) TBD No ** STK-05 Antithrombotic Therapy by the End of Day Two 0438 * or Q4) TBD No ** STK-06 Discharged on Statin Medication 0439 * or Q4) TBD No ** STK-08 Stroke Education * or Q4) TBD No ** STK-10 Assessed for Rehabilitation 0441 * or Q4) TBD No ** VTE-1 Venous Thromboembolism Prophylaxis 0371 * or Q4) TBD No ** VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis 0372 * or Q4) TBD No ** December

3 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2020 IQR IQR Value- (VBP) VBP VBP - HAC HAC Compare Healthcare-Associated Infection s CLABSI CAUTI Central Line-Associated Bloodstream Infection (CLABSI) Outcome Catheter-associated Urinary Tract Infection (CAUTI) Outcome Baseline Performance Baseline Performance December 2019 No December 2019 No December 2019 No December 2019 No Colon and Abdominal Hysterectomy SSI American College of Surgeons Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Colon Procedures Hysterectomy Procedures 0753 Baseline Performance December 2019 No December 2019 No MRSA Bacteremia Facility-wide -onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome 1716 Baseline Performance December 2019 No December 2019 No CDI Facility-wide -onset Clostridium difficile Infection (CDI) Outcome 1717 Baseline Performance December 2019 No December 2019 No HCP Influenza Vaccination Coverage Among Healthcare Personnel 0431 October 1, March 31, October No No No No Claims-Based Patient Safety s Hip/Knee Complications -Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) 1550 April 1, March 31, Baseline Performance January 1, December 2019 No No No PSI 04 Death Rate among Surgical Patients with Serious Treatable Complications 0351 July 1, No No No No PSI 90 Patient Safety for Selected Indicators Composite, Modified PSI 90 (Updated Title Patient Safety and Adverse Events Composite) 0531 July 1, No No July 1, December 2019 No Claims-Based Mortality Outcome s MORT-30-AMI MORT-30-HF MORT-30-PN 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (AMI) ization 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Heart Failure (HF) ization 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Pneumonia ization Baseline Performance July 1, Baseline Performance July 1, Baseline Performance July 1, December 2019 No No No December 2019 No No No December 2019 No No No MORT-30-COPD 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Chronic Obstructive Pulmonary Disease (COPD) ization 1893 No No No No MORT-30-STK 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Ischemic Stroke No No No No December

4 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2020 IQR IQR Value- (VBP) VBP VBP - HAC HAC Compare MORT-30-CABG 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery 2558 No No No No Claims-Based Coordination of Care s READM-30-AMI 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Acute Myocardial Infarction (AMI) ization 0505 No No No December 2019 READM-30-PN 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Pneumonia ization 0506 No No No December 2019 READM-30-THA/TKA READM-30-HWR -Level 30-Day, All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) -Wide All-Cause Unplanned Readmission (HWR) July 1, No No No December 2019 No No No No READM-30-COPD 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Chronic Obstructive Pulmonary Disease (COPD) ization 1891 No No No December 2019 READM-30-STK 30-Day Risk Standardized Readmission Rate Following Stroke ization No No No No READM-30-CABG 30-Day, All-Cause, Unplanned, Risk- Standardized Readmission Rate (RSRR) Following Coronary Artery Bypass Graft (CABG) Surgery 2515 No No No December 2019 READM-30-HF 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Heart Failure (HF) ization 0330 No No No No December 2019 AMI Excess Days Excess Days in Acute Care after ization for Acute Myocardial Infarction 2881 No No No No HF Excess Days PN Excess Days Excess Days in Acute Care after ization for Heart Failure Excess Days in Acute Care after ization for Pneumonia No No No No No No No No Claims-Based Payment s MSPB Payment-Standardized Medicare Spending Per Beneficiary (MSPB) 2158 December 31, December 2019 Baseline Performance December 2019 No No No AMI Payment -Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI) 2431 No No No No HF Payment PN Payment -Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care For Heart Failure (HF) -Level, Risk-Standardized Payment Associated with a 30-day Episode-of-Care For Pneumonia No No No No No No No No THA/TKA Payment -Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty April 1, March 31, No No No No Kidney/UTI Payment Kidney/Urinary Tract Infection Clinical Episode- Based Payment December 2019 No No No No December

5 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2020 Cellulitis Payment GI Payment AA Payment Chole and CDE Payment SFusion Payment Cellulitis Clinical Episode-Based Payment Gastrointestinal Hemorrhage Clinical Episode- Based Payment Aortic Aneurysm Procedure Clinical Episode- Based Payment Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Spinal Fusion Clinical Episode-Based Payment IQR IQR Value- (VBP) VBP VBP - HAC HAC December 2019 No No No No December 2019 No No No No December 2019 No No No No December 2019 No No No No December 2019 No No No No Compare Structural Patient Safety s Patient Safety Culture Survey on Patient Safety Culture Safe Surgery Checklist Safe Surgery Check List Use Patient Experience of Care Survey s December 2019 No No No No December 2019 No No No No HCAHPS Consumer Assessment of Healthcare Providers and Systems (including Care Transition [CTM-3] and Communication About Pain composite measure) December 31, Baseline Performance December 2019 No No No Footnotes (*) A hospital may choose to submit this measure as one of the four self-selected ecqms for one quarter of data (Q1, Q2, Q3 or Q4) required for the IQR and the Medicare s reporting requirements. (**) A hospital may choose to submit this measure as either one of the 16 ecqms required for the for attestation (if permissible) or as one of the four self-selected ecqms required for the for submission. Either reporting method is completed via the Net Secure Portal. (***) Attestation is only an option available for EHs and CAHs in specific circumstances when electronic reporting is not feasible under the Medicare. Contact the for further assistance ehrhardship@provider-resources.com. Updates to Document Date of Update Summary of Update December

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