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CMS's New System of Records for the Hospice Quality Reporting Program [Ober|Kaler]

Payment Matters

On April 8, 2014, CMS published in the Federal Register a “Notice of a New System of Records (SOR).” CMS is establishing a new SOR titled, “Hospice Item Set System” (or HIS). HIS will support the data collection required for the Hospice Quality Reporting Program (HQRP) as mandated by Section 3004(c) of the Patient Protection and Affordable Care Act of 2010 (ACA). Section 3004(c) of the ACA directed the Secretary of HHS to establish a quality reporting program for hospices that collects, compiles, and eventually publishes data measuring the quality of care provided to patients receiving their hospice benefit. The rule goes into effect on May 8, 2014.Comments on the rule are also due May 8, 2014.

As part of the HQRP, all Medicare-certified hospices are required to submit quality data to CMS. Currently, these hospices submit quality data in the form of facility-level quality measures. CMS selects these quality measures for each HQRP cycle. Hospices are notified of the HQRP quality measures, data collection periods, data submission deadlines, and other requirements through the rule making process. The HQRP operates on a cycle that spans three years, and this cycle includes data collection, data submission, and payment impact. For example, for the first reporting cycle, hospices collected data in 2012 and submitted the data by specific deadlines in 2013. This data impacts the Annual Payment Update (APU) for FY 2014. For more information on the HQRP, see CMS’s website at

Under HIS, hospices will be required to submit data not only for Medicare patients, but for non-Medicare patients as well. One of the purposes of HIS is to collect data from the medical record to address symptom management, patient preferences, and care coordination. It will also house data needed for the HQRP, which data CMS will compile and eventually publish.

HIS is intended to confirm that the “appropriate assessments were made and inquiries or concerns were addressed for each patient at the time of admission for the following domains of care: (1) Pain; (2) Respiratory Status; (3) Medications; (4) Patient Preferences; and (5) Beliefs & Values.” CMS will collect seven quality measures – six National Quality Forum (NQF) endorsed quality measures and one modified NQF endorsed measure: (1) Pain Screening; (2) Pain Assessment; (3) Dyspnea Screening; (4) Dyspnea Treatment; (5) Patients Treated With an Opioid who are Given a Bowel Regimen; (6) Treatment Preference; and (7) Beliefs/values addressed.

Beginning July 1, 2014, hospices will be required to submit two HIS records for each admitted patient – a HIS admission record and a HIS discharge record. Hospices have 14 days to complete the HIS admission record and seven days to complete the HIS discharge record, and then have 30 days from admission or discharge to electronically submit the appropriate HIS record to CMS. For more information on HIS, see CMS’s website at

CMS also identified a number of intended routine use disclosures of the collected information, including disclosures to Medicare contractors, as well as government entities with the authority to investigate fraud, waste or abuse.

Ober|Kaler’s Comments

Although the new reporting requirements for hospices go into effect on May 8, 2014, interested providers should still submit comments by the comment deadline, also May 8, 2014, as CMS has stated that it may publish an amended notice in light of submitted comments.

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