FY 2022 IPPS Proposed Rule Now on Display (05/06/2021)
The FY 2022 IPPS Proposed Rule is on display. The proposed rule is scheduled to be published on May 10, 2021.
A PDF version is available at the following URL:
Extraordinary Circumstances Extension/Exception (ECE) due to Texas Winter Storms (04/20/2021)
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 located in areas affected by the Texas Severe Winter Storm to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.
Affected counties designated by the Federal Emergency Management Agency (FEMA) under the Texas Severe Winter Storm (DR-4586-TX) disaster declarations are located at Designated Areas: Disaster 4586 under sections Public Assistance PA-A and PA-B of the FEMA website. If FEMA expands the current emergency disaster declarations to include additional counties, sections PA-A and PA-B will be updated to reflect the newly designated counties.
Providers located outside the counties listed in the FEMA disaster declaration 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 ECE procedure for the respective program(s). In addition, providers located within a county listed in the FEMA disaster declaration who seek an exception for a reporting requirement not covered by this communication may request an individual exception using the applicable ECE procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis.
Hospitals should be aware of the potential impact to reporting requirements and payment programs when deciding whether or not to report data included in the exceptions. If data is submitted, it may be publicly reported or used in scoring.
Please refer to the ECE request process and form specific to the program for additional information.
CMS is granting an exception for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey:
June 2021 HCAHPS submission deadlines for discharge periods:
January 1, 2021 – March 31, 2021 (1st Quarter 2021)
Additional information regarding CMS' response to the Texas winter storms is located at https://www.cms.gov/newsroom/press-releases/cms-offers-comprehensive-support-state-texas-combat-winter-storm.
NEW! AHRQ CAHPS Webcast “Data Analyses That Support Improvement in Patient Experience” Now Available (04/14/2021)
This webcast is the second in a series of three presentations focused on supporting healthcare organizations in using AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys to improve patient experience. Speakers discussed their use of different data analysis methods to better understand patients’ experiences, focus improvement efforts, identify potential solutions, and track the impact of interventions.
HCAHPS Quality Assurance Guidelines V16.0 Appendices Now Available Online (03/11/2021)
The HCAHPS Quality Assurance Guidelines V16.0 with appendices has been released. This updated version is now available online to view or download on the Quality Assurance page.
Translations for the HCAHPS Quality Assurance Guidelines V16.0 Survey Materials Now Posted (03/11/2021)
Translations of the HCAHPS mail, telephone and IVR survey materials are now available. Please click here to access the Survey Instruments page.
HCAHPS Quality Assurance Guidelines V16.0 Change Matrix: Updates and Emphasis Has Been Posted (03/11/2021)
The HCAHPS Quality Assurance Guidelines V16.0 Change Matrix: Updates and Emphasis is a reference tool that highlights the major changes from the HCAHPS Quality Assurance Guidelines V15.0 to V16.0. The reference tool is available on the Quality Assurance page.
Update Training Slides Have Been Updated and Reposted (03/10/2021)
Update Training slides have been updated to correct an error on slide 78. The word “mail” has been changed to “telephone” in the bullet, “For patients without an email address, the telephone survey is the first contact.”
“Hospital at Home” Inpatients and Exception Requests (03/10/2021)
As mentioned during 2021 HCAHPS Update Training, CMS has determined that “hospital at home” inpatients are eligible for the HCAHPS Survey if the hospitalization included an overnight stay in the actual hospital and the patients meet HCAHPS eligibility requirements and do not belong to any of the categories that are excluded from the survey. For more information, please see pp. 59-63 of HCAHPS Quality Assurance Guidelines, V16.0.
Please note: During the Q&A portion of HCAHPS Update Training it was incorrectly stated that Exception Requests were not required for “hospital at home” patients. The HCAHPS Project Team would like to clarify that Exception Requests should be submitted for these patients.
The HCAHPS Fact Sheet Has Been Revised (03/01/2021)
The HCAHPS Fact Sheet has been revised and is posted to the Facts page. The update includes information pertaining to HCAHPS Survey contact and administration, HCAHPS Measures, HCAHPS Public Reporting on Care Compare, HCAHPS Star Ratings, HCAHPS and Hospital Value-Based Purchasing, and a review of revisions to HCAHPS. Click here to access the Facts page.
HCAHPS Quality Assurance Guidelines V16.0 Now Available Online (02/26/2021)
The HCAHPS Project Team is pleased to announce the release of the HCAHPS Quality Assurance Guidelines V16.0. This manual has been revised from V15.0 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 V16.0 Survey Materials Now Posted (02/26/2021)
The HCAHPS mail, telephone and IVR survey materials in English are now available. Translations of the survey materials will be available by March 12, 2021. Please click here to access the Survey Instruments page.
HCAHPS Public Reporting Periods for January 2020 Through October 2021 Have Been Posted (01/21/2021)
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.
Hospital Compare/Care Compare Refresh and Overall Hospital Quality Star Rating 2021 Updates (11/13/2020)
On November 10, 2020, CMS announced that due to the COVID-19 public health emergency, the HCAHPS Data on Hospital Compare/Care Compare will not be updated for the January and April 2021 Public Reports. The data currently on Hospital Compare/Care Compare (October 2020) will remain in its place.
Hospital Compare/Care Compare Has Been Refreshed (10/28/2020)
The October 2020 Hospital Compare/Care Compare Refresh includes HCAHPS scores from January 2019 through December 2019 data collections.
Summary Analyses Page Tables Have Been Updated (10/28/2020)
The following tables have been added to the HCAHPS Web site Summary Analyses page:
The Star Ratings Distributions Have Been Updated (10/28/2020)
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 (10/28/2020)
The HCAHPS Survey Individual Question Top-Box Scores table has been added to the Summary Analyses page:
October 2020 Public Report: January 2019 – December 2019 discharges
V.38 MS-DRG Codes Effective October 1, 2020 (10/07/2020)
CMS has adopted V.38 MS-DRG Codes effective October 1, 2020. Please click here for the Table of V.38 MS-DRG Codes and HCAHPS Service Line Categories.
CMS Clarifies Policy Regarding Requirement of 300 Completed HCAHPS Surveys in Periods Affected by the COVID-19 ECE (10/05/2020)
The 300 completed HCAHPS Surveys standard applies to every 4-quarter roll-up period in which HCAHPS data collection and submission were required in all four quarters. However, the 300 competes standard does NOT apply to any 4-quarter roll-up period in which HCAHPS data collection was not required for one or more quarter. Due to the COVID-19 ECE for Q1 and Q2 2020, the 300 completes standard does NOT apply to the following 4-quarter roll-up periods:
Please refer to the CMS Exceptions and Extension for Quality Reporting Requirements memorandum dated March 27, 2020, for Q1 and Q2 2020 information.
CMS Announces Clarification of Participation in the HCAHPS Portion of the FY 2022 Hospital Value-Based Purchasing Program for IPPS Hospitals (10/05/2020)
IPPS hospitals must achieve at least 100 completed HCAHPS Surveys in a calendar year in order to participate in the HVBP program. Because data from Q1 and Q2 2020 will not be used in Hospital VBP, IPPS hospitals must achieve at least 100 completed surveys in Q3 and Q4 2020 in order to participate in the HCAHPS portion of the FY 2022 HVBP program.
For more information about the Hospital VBP program in the current fiscal year, refer to the CMS Web site (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Hospital-Value-Based-Purchasing-.html).
Announcement: CMS Update on HCAHPS Data for Hospital Value-Based Purchasing Program (HVBP) Q1 and Q2 2020 (09/18/2020)
On September 2, 2020 CMS released additional guidance for the Hospital Value-Based Purchasing (HVBP) Program via an interim final rule. In this rule, CMS is revising the current nation-wide ECE granted for the Hospital VBP Program with respect to first and second quarter CY 2020 excepted data. Under the revised ECE, CMS will not use any first or second quarter CY 2020 excepted Hospital VBP data that hospitals optionally reported to calculate total performance scores (TPS) for the FY 2022 through FY 2025 program years or baseline scores for the FY 2024 through FY 2030 program years. CMS will still use optionally reported fourth quarter CY 2019 Hospital VBP Program data to calculate TPSs for those hospitals for the FY 2021 through FY 2024 program years and baseline scores for the FY 2026 through FY 2029 program years. No additional ECE is necessary for Q1, Q2 2020 for the HVBP program.
NEW! Care Compare Web Site Now Available (09/03/2020)
CMS Care Compare Empowers Patients when Making Important Health Care Decisions
The Centers for Medicare & Medicaid Services (CMS) launched Care Compare, which contains HCAHPS survey results and many other measures, and is a streamlined redesign of eight existing CMS healthcare compare tools available on Medicare.gov.
Full Press Release can be found here: https://www.cms.gov/newsroom/press-releases/cms-care-compare-empowers-patients-when-making-important-health-care-decisions
Direct links to the tools & additional resources
Care Compare on Medicare.gov - https://www.medicare.gov/care-compare/
Provider Data Catalog on CMS.gov - https://data.cms.gov/provider-data/
Provider Data Catalog and Medicare Care Compare
Webinar Recordings Now Available
Go to the “Videos” Section on the CMS National Training Program page here. Direct links below:
HCAHPS Service Line Benchmark Top-Box Scores Are Now Available on the Summary Analyses Page (08/18/2020)
CMS and the HCAHPS Project Team have calculated benchmarks for “top-box” scores for each service line included in the HCAHPS Survey: Medical, Surgical, and Maternity. The Service Line Benchmark tables provide the percentile distributions, mean, and standard deviation of top-box scores for publicly reported HCAHPS measures within each of the three service lines. These tables permit a hospital to assess its performance in each service line relative to that of other hospitals.
CMS Announces Improvements to HCAHPS Data Submissions (08/14/2020)
On August 13, 2020, a QualityNet Notification was distributed regarding important upcoming changes to HCAHPS Data submission. To review the entire Quality Reporting Notification, please click here.
The Centers for Medicare & Medicaid Services (CMS)'s ongoing effort to improve data collection has given way to a new method to submit XML files for HCAHPS data. Starting 08/18/2020, Secure File Transfer (Axway) will no longer be available for data submissions. You will be required to submit your XML files directly within Hospital Quality Reporting (HQR) using the File Upload tool in the new QualityNet Secure Portal. This new requirement should reduce the time you spend to submit data.
For further assistance regarding this message, please contact the QualityNet Help Desk at (866) 288-8912 or email@example.com.
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.
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 firstname.lastname@example.org should you have questions regarding this information.
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 email@example.com 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 (firstname.lastname@example.org) if your approved organization encounters difficulties accessing the SAFE.
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.
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) (04/20/2021)
For recent Extraordinary Circumstances Extensions (ECE) the key HCAHPS content is displayed below. To review the entire Quality Reporting Notifications 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 (5/6/21)