CMS Updated Quality Reporting in the Open Door Forum

The Centers for Medicare & Medicaid Services (CMS) provided some important quality updates in the Tuesday, December 14 Home Health, Hospice, and DME (Durable Medicare Equipment) Open Door Forum (ODF). What follows is a detailed summary of those updates from a NAHC staffer who monitored the call.


CMS reminded hospices that the FY2024 annual payment update is based on the CY2022 data submissions.  Hospices must comply with the following HIS and Hospice CAHPS Survey participation requirements to avoid the APU penalty which increases to 4% in FY2024.

  • Submit at least 90% of HIS records within the 30 days of the event date (patient’s admission or discharge) for patient admissions/discharges occurring 1/1/22 – 12/31/22
  • Ongoing monthly participation in the CAHPS Hospice Survey 1/1/22 – 12/31/22

CMS also reminded hospices that it recognizes that there are instances where an extraordinary or extenuating circumstance beyond the hospice’s control (e.g., natural disasters) may delay or prevent submission of required data, and hospices can submit requests for an extension or exemption within 90 days of the extraordinary circumstance event.  NAHC encourages hospices to review the HQRP webpage devoted to these instances for more information and to submit a request for an extension or exemption when warranted.  While the example CMS uses for such a circumstance is a natural disaster there are other circumstances that are out of the hospice’s control and impact its ability to submit quality data such as the current COVID pandemic.

Public reporting for hospices will resume with the February 2022 refresh on Care Compare. This refresh excludes Q1 and Q2 2020 data due to the Public Health Emergency (PHE) exemption of data submission requirements for these quarters.  So, CMS will use fewer quarters of data than usual for this refresh due to this exemption.  CMS plans to post a public reporting tip sheet later this week with more information about public reporting.

The Hospice Quality Reporting Program Quality Measure Specifications User’s Manual v1.00 is now available and reflects changes in the FY2022 hospice final rule, specifically the new Hospice Care Index (HCI) and Hospice Visits in Last Days of Life (HVLDL) measures. Updated documents related to the current measures including the Manual, a change table, and updated measures are available on the Current Measures webpage.

Materials from the HQRP webinar CMS held on October 19 are available in the Downloads section of the Provider & Stakeholder Engagement webpage.

Hospices should review documents available in the Downloads and Provider Toolkit sections of the Requirements & Best Practices webpage as there are updated provider resource documents available.