User Guide for Hospice Quality Reporting Data Collection
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User Guide for Hospice Quality Reporting Data Collection Reporting cycle: Data Collection from October 1, 2012 – December 31, 2012 Data Submission January 1, 2013, and April 1, 2013 Annual Payment Update impact FY 2014 Version 1.2 Last Updated: 12/19/12 PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1153. The time required to complete this information collection for both measures combined is estimated to average 181 hours per hospice per year, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. OMB Control # 0938-1153 Expiration Date 9/30/2015 Section Page # Original Text Revised Text Cover 1 Version 1.1 Version 1.2 Last Updated: 9/5/12 Last Updated: 12/19/12 This User Guide is considered a PRA Disclosure Statement: According draft until OMB approval of the to the Paperwork Reduction Act of data submission is received. 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1153. The time required to complete this information collection for both measures combined is estimated to average 181 hours per hospice per year, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. OMB Control # 0938-1153 Expiration Date 9/30/2015 I 6 The data entry site is not yet • Providers can access the data entry available for provider use. site through the “Data Submission” The data entry site will go live for portion of the CMS HQRP website, provider use on January 1, 2013. here: For updates on data entry website http://www.cms.gov/Medicare/Qualit location and availability, please check y-Initiatives-Patient-Assessment- the “Spotlight and Announcements” Instruments/Hospice-Quality- section of the CMS Hospice Quality Reporting/Data-Submission.html, at Reporting Program website at: the bottom of the webpage under http://www.cms.gov/Medicare/Quality- “Related Links”. Initiatives-Patient-Assessment- Instruments/Hospice-Quality- • The data entry site will be active for Reporting/ data entry and submission January 1 – April 1, 2013. I 7 Important Information Other Resources. Data Entry Site Availability: -User Guides Available for Providers: This Data Collection User Guide will provide hospice providers with This Data Collection User Guide will instruction only about provide hospice providers with data collection for elements that will be instruction only about required for CMS reporting. data collection for elements that will be Version 1.2 - January 2013 Page 2 of 57 Section Page # Original Text Revised Text THE DATA ENTRY WEBSITE IS required for CMS reporting. NOT YET AVAILABLE FOR There is also a Technical User Guide PROVIDER USE. for Hospice Quality Reporting Data The site is scheduled to go live for Entry and Submission available for provider use on January 1, 2013. provider download on the “Data Availability of the data entry site along Submission” portion of the CMS HQRP with a User Guide for Data Submission website: will be http://www.cms.gov/Medicare/Quality- announced on the “Spotlight and Initiatives-Patient-Assessment- Announcements” section of the CMS Instruments/Hospice-Quality- HQRP site at: Reporting/Data-Submission.html at the bottom of the webpage, under http://www.cms.gov/Medicare/Quality- “Downloads”. Providers should review Initiatives-Patient-Assessment- both guides prior to beginning the data Instruments/Hospice-Quality- entry process. Reporting/Spotlight.html Trainings Available for Providers: Frequently Asked Questions: There are two trainings available for A Question + Answer document is provider download: available for provider download on the CMS HQRP website in i. April 2012 webinars for training on the “Spotlight and Announcements” data collection processes for the section under “Downloads” at the structural measure and the NQF bottom of the page. This document #0209 measure are available for contains frequently asked questions download on the CMS website here: pertinent to FY 2014 Hospice Quality http://www.cms.gov/Medicare/Qual Reporting. ity-Initiatives-Patient-Assessment- The document will be updated Instruments/Hospice-Quality- periodically as new questions are Reporting/Spotlight.html at the received at the Help Desk(s). bottom of the webpage under http://www.cms.gov/Medicare/Quality- “Related Links”. Initiatives-Patient-Assessment- Instruments/Hospice-Quality- ii. WebEx training webinar on data Reporting/Spotlight.html entry/submission processes. The Hospice Quality Reporting Program Data Entry and Submission WebEx is available for download on the QTSO website here: https://www.qtso.com/hospicetrain. html iii. Both webinars are pre-recorded. Providers do not need to register to view the webinars and can download and view them as many times as they’d like. Version 1.2 - January 2013 Page 3 of 57 Section Page # Original Text Revised Text I 8 Phone: 1-800-647-9670 (2 business day call-back service) Hours: Monday – Friday 8:30 a.m. – 4:30 p.m. Eastern Time *For quickest turnaround time with provider quality questions, please contact the Quality Help Desk by e-mail.* II 11 To facilitate this “data collection” To facilitate this “data collection” process, hospice providers may process, hospice providers may complete Appendix A: Structural complete Appendix A: Structural Measure Worksheet in this User Guide. Measure Worksheet in this User Guide. It is highly recommended that providers It is highly recommended that providers complete the Appendix A worksheet; complete the Appendix A worksheet; having a completed worksheet will having a completed worksheet will expedite the data submission process expedite the online data entry and once the data entry site goes live on submission process. See Figure 1 January 1, 2013. See Figure 1 below below for additional details. for additional details. II 13 In order to have the necessary In order to have the necessary information to comply with structural information to comply with structural measure reporting, it is recommended measure reporting, it is recommended that hospice providers complete Steps I that hospice providers complete Steps I to IV outlined below. Please note, some to IV outlined below. Please note, some of the steps below make use of of the steps below make use of Appendix A: Structural Measure Appendix A: Structural Measure Worksheet. Providers may wish to have Worksheet. Providers may wish to have a copy of Appendix A readily available a copy of Appendix A readily available for completion. The Appendix A for completion. The Appendix A worksheet is formatted to match Q1 to worksheet is formatted to match Q1 to Q3 as they will appear on the data entry Q3 as they will appear on the data entry site, therefore it is highly site, therefore it is highly recommended that providers recommended that providers complete Appendix A prior to data complete Appendix A prior to entry site availability to facilitate the beginning online data entry in order data entry process. to facilitate the data entry and submission process. II 15 • Patient safety or incidents, general • Patient safety or incidents, generally Version 1.2 - January 2013 Page 4 of 57 Section Page # Original Text Revised Text II 18 Please note, the data entry This Guide is intended only to provide site is not yet available for hospice providers with details on data provider use. collection processes . The site is scheduled to go live A Technical User Guide for Hospice for provider use on January Quality Reporting Data Entry and 1, 2013. Submission is available on the “Data This Guide is intended only to provide Submission” portion of the CMS hospice providers with details on data HQRP website here: collection processes for these three http://www.cms.gov/Medicare/Quality- questions. A Data Submission User Initiatives-Patient-Assessment- Guide will be made available once the Instruments/Hospice-Quality- data entry site is available for provider Reporting/Data-Submission.html at the use. Data entry will consist of three bottom of the page, under questions (Q1 to Q3), outlined in the “Downloads”. following pages. Providers should review both the Data Collection User Guide and the Data Submission User Guide prior to beginning data entry on the data entry and submission website. The weblink to the data entry and submission website is available on the “Data Submission” portion of the CMS HQRP website here: http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/Hospice-Quality- Reporting/Data-Submission.html at the bottom of the page, under “Related Links.” II 19 THE DATA ENTRY SITE IS NOT YET AVAILABLE FOR PROVIDER USE. The Data Entry Site is scheduled to go live for provider use on January 1, 2013. Availability of the data entry site and a User Guide for Data Submission will be announced in the “Spotlight and Announcements” section of the CMS Hospice Quality Reporting Program site at: http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/Hospice-Quality- Reporting/Spotlight.html Version 1.2 - January 2013 Page 5 of 57 Section Page # Original Text Revised Text III 26 − Hospices should make every effort to contact the patient sometime between 48 and 72 hours after the initial pain assessment to ask the measure follow-up question.