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.
IPPS and OPPS Rules
FY 2021 IPPS Final Rule Has Been Published (09/18/2020)
The FY 2021 IPPS Final Rule, is now available on the Federal Register.
The Final Rule and related tables are available at the following URL: federalregister.gov/d/2020-19637
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.
HCAHPS XML File Specifications V4.3 Have Been Posted (09/11/2020)
The HCAHPS XML File Specifications Version 4.3 have been added to the HCAHPS Web site Technical Specifications page. The HCAHPS Technical File Specifications V4.3 are to be used starting with July 1, 2020 patient discharges.
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.
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
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.
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 (firstname.lastname@example.org) 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 (email@example.com) 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 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.
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.
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.
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) (11/07/2019)
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 (10/15/20)