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Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals and vendors that the Hospital Quality Reporting (HQR) System is now accepting electronic clinical quality measure (eCQM) data for the calendar year (CY) 2024 reporting period. The HQR System now accepts Quality Reporting Document Architecture (QRDA) Category I test and production files using CY 2024 requirements.

Test QRDA Category I data submissions are considered practice submissions, and they do not count towards CMS program credit. Production QRDA Category I data submissions by hospitals, or by health information technology vendors on the hospital’s behalf, count as final data submissions to fulfill the eCQM reporting requirements for the Hospital Inpatient Quality Reporting (IQR) and Medicare Promoting Interoperability Programs.

*What are the CY 2024 eCQM reporting requirements? *

Hospitals are required to submit four quarters of data using Office of the National Coordinator for Health Information Technology (ONC) certification criteria [ https://www.healthit.gov/topic/certification-ehrs/about-onc-health-it-certification-program ] by the submission deadline of *Friday, February 28, 2025, 11:59 p.m. Pacific Time (PT), *for all of the following:


* Three CMS-selected eCQMs: Safe Use of Opioids-Concurrent Prescribing; Cesarean Birth (Perinatal Care [PC]-02); and Severe Obstetric Complications (PC-07)* *
* Three self-selected eCQMs from the CY 2024 Available eCQMs Table [ https://qualitynet.cms.gov/files/66ec6f4deae0176601c8ae9d?filename=CY_2024_Avail_eCQMsTable_Sept.pdf ]

Each quarter must contain the mandatory Safe Use of Opioids-Concurrent Prescribing; Cesarean Birth (PC-02); and Severe Obstetric Complications (PC-07) eCQMs *_and_* at least three self-selected eCQMs. The eCQMs must be the same eCQMs across all four quarters.

The successful submission of CY 2024 eCQM data will apply towards the Hospital IQR and Medicare Promoting Interoperability Programs, impacting the fiscal year (FY) 2026 payment determination for eligible hospitals and the FY 2024 payment determination for critical access hospitals.

Successful submission of eCQM data includes any combination of QRDA Category I production files with patients meeting the initial patient population of the applicable measure(s), zero denominator declarations, and/or case threshold exemptions.

Important: Hospitals that do not have patient-level data meeting the initial patient population for the mandatory measures must submit a zero denominator declaration for each applicable quarter.

CY 2024 program requirements are posted on the QualityNet [ https://qualitynet.cms.gov/inpatient/measures/ecqm/participation ] and CMS.gov [ https://www.cms.gov/regulations-guidance/promoting-interoperability/2023-program-requirements ] websites.

*Note:* The Medicare Promoting Interoperability Program [ https://www.cms.gov/regulations-guidance/promoting-interoperability/2023-program-requirements ] requirements and attestation deadline for eligible hospitals and critical access hospitals is also *Friday, February 28, 2025, 11:59 p.m. PT.*

*Where are the technical materials for reporting eCQMs for the CY 2024 reporting period? *

The Electronic Clinical Quality Improvement (eCQI) Resource Center [ https://ecqi.healthit.gov/ ] is the one-stop shop for the most current resources to support electronic clinical quality improvement. Reference materials are available for download. They include an eCQM annual update implementation checklist, CY 2024 QRDA Category I Implementation Guide (IG), Schematron and sample files, eCQM specifications, eCQM Flows, and the eCQM value set addendum.

*Where can I learn about changes to the CY 2024 QRDA Category I IG for HQR and updates to the Health Level Seven (HL7) base standard? *

Visit the archived events page of the Quality Reporting Center [ https://www.qualityreportingcenter.com/en/ ] website to review materials from the "Reporting eCQM and Hybrid Measure Data Using the 2024 CMS QRDA Category I Implementation Guide" [ https://www.qualityreportingcenter.com/en/inpatient-quality-reporting-programs/hospital-inpatient-quality-reporting-iqr-program/2024-events/ecqmondemand/ ]" "webinar. Slides 16–36 outline IG changes, show document-level template changes, and reviews common errors that cause file rejections.

*Where can I locate resources to assist with the CY 2024 eCQM data submission process?*

Resources and tools for CY 2024 eCQM reporting are available for download from the QualityNet eCQM Resources [ https://qualitynet.cms.gov/inpatient/measures/ecqm/resources ] web page and the eCQM Resources and Tools [ https://www.qualityreportingcenter.com/en/inpatient-quality-reporting-programs/other-programs/resources-and-tools/ ] web page on the Quality Reporting Center website. The following tools are available:


* CY 2024 eCQM QRDA Category I File Submission Checklist [ https://qualitynet.cms.gov/files/66e1d65ceae0176601c7d3f4?filename=CY_2024_eCQM_QRDA_SbmsnChklst.pdf ]
* CY 2024 eCQM Submission Overview [ https://qualitynet.cms.gov/files/66ec70302702fb414b5151cd?filename=CY_2024_eCQM_SbmsnOvrvw_Sept.pdf ]
* CY 2024 Available eCQMs Table [ https://qualitynet.cms.gov/files/66ec6f4deae0176601c8ae9d?filename=CY_2024_Avail_eCQMsTable_Sept.pdf ]

*Contact Information*

*Topic***



*Contact***



*Phone***



*Link/Email***



HQR System, (user roles, reports, data upload, and troubleshooting file errors)



Center for Clinical Standards and Quality Service Center



(866) 288-8912



QNetSupport@cms.hhs.gov



Log issues regarding eCQM implementation or to ask questions regarding eCQM specifications, logic, data elements, standards, or tools



ONC JIRA eCQM Issue Tracker



 



https://oncprojectracking.healthit.gov/support/projects/QRDA/summary

 



QRDA development and implementation or to ask QRDA-related questions



ONC Jira QRDA Issue Tracker



 



https://oncprojectracking.healthit.gov/support/projects/QRDA/summary

 



Medicare Promoting Interoperability Program and Hardship Exception Process



Quality Question and Answer Tool



 



https://cmsqualitysupport.servicenowservices.com/qnet_qa



Hospital IQR Program and Extraordinary Circumstances Exceptions process



Inpatient and Outpatient Healthcare Quality Systems Development and Program Support



(844) 472-4477



https://cmsqualitysupport.servicenowservices.com/qnet_qa



 

*Please do not respond directly to this email.*

 

 

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