New Point of Origin Code for Transfer from a Designated Disaster Alternate Care Site (07/31/2020)
Due to changes relative to the COVID-19 Public Health Emergency (PHE), the National Uniform Billing Committee (NUBC) has created a new Point of Origin Code G. This code is effective August 3, 2020 and is defined as “Transfer from a Designated Disaster Alternative Care Site (ACS).”
For purposes of HCAHPS data submission, Point of Origin Codes align with the Admission Source in the XML Administrative Data Record. Hospitals and/or survey vendors should crosswalk Point of Origin Code G to Admission Source 6, “Transfer from Another Healthcare Facility” for patient discharges occurring on or after August 3, 2020.
For more information about these changes in coding point of admission, please see the MLN Matters document at https://www.cms.gov/files/document/MM11836.pdf. To learn more about ACS, visit the CMS Web site at https://www.cms.gov/files/document/covid-state-local-government-fact-sheet-hospital-alternate-care-sites.pdf.
Please note: Patients who transfer from a designated disaster Alternative Care Site (ACS) are eligible for the HCAHPS Survey if they meet the HCAHPS eligibility criteria and are not otherwise deemed ineligible. For information regarding HCAHPS eligibility criteria, please see pages 60-62 of the Sampling Protocol chapter of the HCAHPS Quality Assurance Guidelines V15.0 (QAG). The QAG is available for review and download by visiting the HCAHPS Web site at www.hcahpsonline.org and selecting the Quality Assurance navigation button.
NEW! HCAHPS Podcast Now Available – Changes to QualityNet Data File Submission (07/31/2020)
Please click here to view the Changes to QualityNet Data File Submission podcast on the Podcasts page.
NEW! HCAHPS Podcast Now Available – Total Inpatient Discharges (07/31/2020)
Please click here to view the Total Inpatient Discharges podcast on the Podcasts page.
Hospital Compare Has Been Refreshed (07/22/2020)
The July 2020 Hospital Compare Refresh includes HCAHPS scores from October 2018 through September 2019 data collections.
Summary Analyses Page Tables Have Been Updated (07/22/2020)
The following tables have been added to the HCAHPS Web site Summary Analyses page:
The Star Ratings Distributions Have Been Updated (07/22/2020)
The following tables have been added to the HCAHPS Web site Star Ratings page:
HCAHPS Survey Individual Question Top-Box Scores Table Has Been Updated (07/22/2020)
The HCAHPS Survey Individual Question Top-Box Scores table has been added to the Summary Analyses page:
July 2020 Public Report: October 2018 – September 2019 discharges
The October 2020 Public Report Preview Period Begins July 16, 2020 (07/16/2020)
The October 2020 Public Report Preview Reports are now available on the QualityNet Secure Portal to participating providers and Quality Improvement Organizations (QIOs). The Preview Reports will be available from July 16, 2020 through August 17, 2020. (To access the report, you must be registered as a QualityNet Secure Portal user and have been assigned the QIO Clinical Data Warehouse Feedback Report role). The data that appear in the Preview Reports will be reported on Hospital Compare, the Centers for Medicare & Medicaid Services Web site for Medicare beneficiaries and the general public, in October 2020.
Patient-Mix Adjustments and National Means for October 2020 HCAHPS Results Have Been Posted (07/16/2020)
The Patient-Mix Adjustments and National Means for the October 2020 HCAHPS results are now available. Please click here to access the Mode & Patient-Mix Adjustment page.
Star Ratings: October 2020 Technical Notes Have Been Posted (07/16/2020)
The Technical Notes for the October 2020 HCAHPS results are now available. The October 2020 HCAHPS Star Ratings are included in the hospital Preview Reports (available to hospitals from July 16, 2020 through August 17, 2020, and will be Publicly Reported on Hospital Compare in October 2020. Please click here to access the HCAHPS Star Ratings page.
Additional HCAHPS Quality Assurance Guidelines V15.0 Survey Material Translations Now Posted (06/25/2020)
Additional translations for the Optional Modified survey materials are now available. Please click here to access the Survey Instruments page. Please note that all approved HCAHPS Survey vendors and self-administering hospitals that intend to utilize these materials must submit survey material samples for each of the language translations that will be used to the HCAHPS Project Team for review, prior to using.
HCAHPS Quality Assurance Guidelines V15.0 Change Matrix: Updates and Emphasis Has Been Posted (05/22/2020)
The HCAHPS Quality Assurance Guidelines V15.0 Change Matrix: Updates and Emphasis is a reference tool that highlights the major changes from the HCAHPS Quality Assurance Guidelines V14.0 to V15.0. The reference tool is available on the Quality Assurance page.
Reminder: HCAHPS Survey Materials and Attestation Statement Submissions Are Due May 15, 2020 (05/05/2020)
The due date for Survey vendors, hospitals administering HCAHPS for multiple sites, and self-administering hospitals currently approved to administer the HCAHPS Survey for survey materials that will be used for July 1, 2020 patient discharges has been extended to May 15, 2020.
Under the current circumstances any organization that anticipates having difficulty meeting the May 15, 2020 deadline is to contact HCAHPS Technical Assistance (email@example.com) as soon as possible.
Survey Materials required to be submitted for the HCAHPS Survey review include:
Note: Be sure to send survey material samples for all of the language translations utilized by your organization
In addition, survey vendors, hospitals administering HCAHPS for multiple sites, and self-administering hospitals currently approved to administer the HCAHPS Survey are required to complete and submit an annual statement that attests to conformance with HCAHPS protocols and verifies that annual updates have been made to the organization’s HCAHPS Quality Assurance Plan (QAP). Please click here to view and print the HCAHPS Attestation Statement form.
Materials may be submitted either via HCAHPS Technical Assistance (firstname.lastname@example.org) or via the HCAHPS Secure Access File Exchange (SAFE) application.
Impact of COVID-19 on HCAHPS Survey Operations for HCAHPS Survey Vendors and Self-administering Hospitals (04/13/2020)
CMS recognizes that the COVID-19 outbreak may impact your survey operations. If you intend to request approval to conduct survey operations from a remote location (other than your place of business), please complete and submit an Exception Request Form online via the HCAHPS Web site (www.hcahpsonline.org). Please remember, survey vendors and self-administering hospitals should take necessary steps to protect staff’s personal health and safety.
Please contact HCAHPS Technical Assistance at email@example.com should you have questions regarding this information.
HCAHPS Quality Assurance Guidelines V15.0 Technical Corrections and Clarifications Document Available (04/03/2020)
Information on technical corrections to the HCAHPS Quality Assurance Guidelines V15.0 has been posted. Please click here to access the Quality Assurance page.
Important Information for HCAHPS Survey Vendors and Self-administering Hospitals: Impact of COVID-19 on HCAHPS Survey Operations (03/23/2020)
Please contact HCAHPS Technical Assistance at firstname.lastname@example.org should you have questions regarding this information.
Secure Access File Exchange (SAFE) (03/09/2020)
A Secure Access File Exchange (SAFE) application has been implemented for document sharing between the HCAHPS Project Team (HPT) and approved HCAHPS Survey vendors and self-administering hospitals. Approved organizations may use the SAFE to upload materials for the HPT to review (i.e., QAP, survey materials, etc.). In addition, the HPT will post documents within the approved organization’s secure folder (i.e., QAG, data record review records, etc.).
The HPT has provided a registration link and user instructions to approved HCAHPS Survey vendors and self-administering hospitals. Please contact HCAHPS Technical Assistance (email@example.com) if your approved organization encounters difficulties accessing the SAFE.
HCAHPS Quality Assurance Guidelines V15.0 Now Available Online (02/19/2020)
The HCAHPS Project Team is pleased to announce the release of the HCAHPS Quality Assurance Guidelines V15.0. This manual has been revised from V14.0 and includes additional updates and enhancements that provide a comprehensive resource for hospitals and survey vendors participating in the HCAHPS initiative. This updated version is now available online to view or download on the Quality Assurance page.
HCAHPS Quality Assurance Guidelines V15.0 Survey Materials Now Posted (02/19/2020)
The HCAHPS mail, telephone and IVR survey materials are now available. Please click here to access Survey Instruments page.
The National Quality Forum (NQF) Has Renewed its Endorsement of the HCAHPS Survey (11/21/2019)
On October 25, 2019, the National Quality Forum (NQF) announced its re-endorsement of the HCAHPS Survey. The NQF is a voluntary consensus and standard-setting organization established to standardize healthcare quality measurement and reporting. The NQF originally reviewed and endorsed the HCAHPS Survey in May 2005 and since then has reviewed and re-endorsed HCAHPS in 2010, 2015, and 2019.
For more information about NQF endorsement renewal, please click here.
HCAHPS Public Reporting Periods for January 2019 Through October 2021 Have Been Posted (11/13/2019)
Click here to view the HCAHPS Public Reporting Periods document. This document indicates which calendar quarters of HCAHPS results will be publicly reported on the Hospital Compare Web site through October 2021.
Please Note: The dates of future preview periods and public reporting are estimates based on current timetables and are subject to change.
Extraordinary Circumstances Extension/Exception (ECE) due to Hurricane Dorian (11/07/2019)
To review entire Quality Reporting Notification, please click here.
Key HCAHPS content is displayed below. Please review the entire notification for additional detail.
The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs to hospitals, skilled nursing facilities, home health agencies, hospices, inpatient rehabilitation facilities, renal dialysis facilities, long-term care hospitals, and ambulatory surgical centers, and Merit-Based Incentive Payment System (MIPS) eligible clinicians located in areas affected by Hurricane Dorian due to the devastating impact of the storm. These healthcare providers and suppliers will be granted exceptions if they are located in one of the states/counties listed below, all of which have been designated by the Federal Emergency Management Agency (FEMA) as an emergency disaster area.
The scope and duration of the exception under each Medicare quality reporting program and value-based purchasing program is described below. CMS is granting exceptions to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.
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 counties designated by FEMA under the Hurricane Dorian Disaster Declarations for the state of South Carolina (DR-4464), the state of North Carolina (DR-4465), and the state of Florida (DR-4468), as of the date of this communication, are as follows:
|South Carolina - DR-4464|
|North Carolina - DR-4465|
|Florida - DR-4468|
The healthcare providers located outside of the states/counties listed above are not covered by this communication, but they may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing 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 Hurricane Dorian to include additional states/counties, CMS will update this communication to reflect the expanded list of applicable states/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.
CMS is granting an exception to subsection (d) hospitals located in designated states/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:
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 firstname.lastname@example.org or call toll-free at (844) 472-4477.
HCAHPS XML File Specifications V4.2 Have Been Posted (10/01/2019)
The HCAHPS XML File Specifications Version 4.2 have been added to the HCAHPS Web site Technical Specifications page. The HCAHPS Technical File Specifications V4.2 are to be used starting with October 1, 2019 patient discharges.
The HCAHPS Fact Sheet Has Been Revised (10/01/2019)
The HCAHPS Fact Sheet has been revised and is posted to the Facts page. The update includes the removal of the communication about pain items that reduced the survey to 29 items. In addition, the document was updated to reference the survey language translations currently available and the podcasts posted to the HCAHPS Web site. Click here to access the Facts page.
V.37 MS-DRG Codes Effective October 1, 2019 (08/27/2019)
CMS has adopted V.37 MS-DRG Codes effective October 1, 2019. Please click here for the Table of V.37 MS-DRG Codes and HCAHPS Service Line Categories.
IPPS and OPPS Rules
FY 2020 IPPS Final Rule Has Been Published (08/16/2019)
The FY 2020 IPPS Final Rule, establishing the Hospital Inpatient Prospective Payment System (IPPS), is now available on the Federal Register.
The Final Rule and related tables are available at the following URL:
Previous IPPS Final Rules:
CY 2019 OPPS Final Rule Now Published (11/21/2018)
The CY 2019 OPPS Final Rule is now published.
The Final Rule and related tables are available at the following URL: https://www.gpo.gov/fdsys/pkg/FR-2018-11-21/pdf/2018-24243.pdf
Combating the Opioid Crisis
In response to recommendations from the President’s Commission on Combating Drug Addiction and the Opioid Crisis, to comply with the requirements of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (P.L. 115-271), and to avoid any potential unintended consequences, under the Hospital Inpatient Quality Reporting (IQR) Program, CMS is finalizing the proposal to update the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey measure by removing the three recently revised pain communication questions. The removal of these questions is effective with October 2019 discharges, for the FY 2021 payment determination and subsequent years, earlier than proposed. As a related modification, CMS will not publicly report the three revised Communication About Pain questions.
Previous OPPS Final Rules:
CMS is finalizing the removal of the Pain Management dimension from the scoring formula used in the Hospital Value-Based Purchasing Program (Hospital VBP), beginning with the FY 2018 payment adjustments. The Pain Management dimension is derived from Questions 12, 13 and 14 on the HCAHPS Survey.
CMS to Review HCAHPS Content with Patients and Feasibility of Mixed Mode that Includes a Web Survey (06/21/2019)
CMS has begun to take steps to obtain feedback directly from patients about topics that are most important to them in the current HCAHPS Survey, as well as additional topics that might be added in the future. This is part of a broader effort that CMS is undertaking to evaluate the items currently included in HCAHPS. CMS also plans to investigate the feasibility of a new Mixed Mode that would include a Web survey. Pending approval from the Office of Management and Budget, CMS will test a web mode of administration for several patient experience surveys, including HCAHPS. Please continue to monitor the HCAHPS Web site for important updates on these topics.
Updates to All Documents Pertaining to April 2018 Public Report and the Pain Management Composite (06/15/2018)
On May 23, 2018, the Hospital Compare Web site posted the following announcement regarding the HCAHPS Pain Management composite scores:
May 23, 2018 update: The Centers for Medicare & Medicaid Services (CMS) has suppressed the HCAHPS Pain Management composite scores on Hospital Compare and in the downloadable databases. In July, CMS is planning to remove the Pain Management composite from Hospital Compare and downloadable databases, and exclude it from the calculation of the HCAHPS Summary Star Rating and the Hospital Compare Overall Hospital Quality Star Rating.
As a result, HCAHPS Online is making the corresponding updates to all documents pertaining to the April 2018 public report period that are posted on this web site.
Beginning With the July 2018 Public Report, CMS Will No Longer Report the HCAHPS Pain Management Composite Measure (05/04/2018)
The survey questions comprising Pain Management Composite 4 were removed from the HCAHPS Survey in the FY 2018 IPPS/LTCH PPS Final Rule (81 FR 38342). Composite 4 is no longer needed and will no longer be reported on Hospital Compare. July 2018 Preview Reports and public reporting will display “N/A” and Footnote 5 for the Pain Management measure and will display “N/A” and Footnote 15 for the Pain Management star rating. In addition, Pain Management is no longer included in the calculation of the HCAHPS Summary Star Rating or the Hospital Compare Overall Hospital Quality Star Rating.
Extraordinary Circumstances Extension (ECE) (03/08/2019)
For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below. Please review the entire notification for additional details.
To review the entire Quality Reporting Notifications for Tropical Storm Barry, California Wildfires, Hurricane Michael, Hurricane Florence, Hurricane Nate, Hurricane Irma, and Hurricane Harvey please click below:
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.
This page was last modified on (7/31/20)