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Hospice Quality Reporting Requirements for FY2014

To: NHPCO Members
From: NHPCO Health Policy Team
Date: November 08, 2012

Final Hospice Quality Reporting Requirements for FY2014 published

The CY2013 HH PPS Payment, Hospice Quality Reporting Final Rule was published in the Federal Register on November 8, 2012.  The FY2013 Final Rule confirms that CMS will not require any additional measures for the 2014 payment year.

Quality Measures and Data Submission Requirements for Payment Year 2014

The FY 2012 Final Rule (published August 2, 2011 stated the requirements for quality reporting that began in 2012 with two measures. The final rule requires hospices to report:

  1. NQF #0209: Pain Management
    The percentage of patients who report being uncomfortable because of pain on the initial assessment (after admission to hospice services) who report pain was brought to a comfortable level within 48 hours.
  2. Structural Measure: Participation in a Quality Assessment and Performance Improvement (QAPI) Program that Includes at Least Three Quality Indicators Related to Patient Care

Hospice programs will report whether or not they have a QAPI program that addresses at least three indicators related to patient care.  A drop-down menu with check off for all patient care topics for which hospice has a QAPI indicator will be available for data submission.  No results are required to be submitted, only patient care measures.  Hospice programs will be evaluated based on whether or not they submit, not on how they respond or on performance level.

Hospices will submit data on quality measures on a web-based data entry site. Training on the use of the web-based data submission form will be provided to hospices through webinars and other downloadable materials before the data submission date. For hospices that cannot complete the web based data entry, a downloadable data entry form will be available upon request.

WebEx training on the Hospice Quality Reporting Program Data Entry and Submission

CMS has posted information on the Spotlight & Announcement page of the Hospice Quality Reporting website about the upcoming availability of WebEx training for hospices. The training will help hospices prepare for web-based data entry and submission of quality data affecting the FY 2014 payment determination. The WebEx will be available beginning the week of November 12, 2012.  Hospices can access additional details about the WebEx on the CMS website.  

Quality Measures for Hospice Quality Reporting Program for Payment Year FY 2015 and Beyond

To meet the quality reporting requirements for the FY 2015 payment determination year and each subsequent year, hospices will continue to report on:

  • NQF #0209: Pain Management
  • Structural Measure:  Participation in a QAPI Program that Includes at Least Three Quality Indicators Related to Patient Care

    Hospices will no longer be required to provide a list of patient care indicators as part of the submission for the QAPI Structural Measure.  

Reporting Periods and Deadlines

  • All hospice quality reporting periods will be based on a calendar year rather than a calendar quarter. The submission deadline for all measures will be April 1 of each year.
  •  Hospices submit data in the fiscal year prior to payment determination. This means that the next reporting period will be January 1, 2013 through December 31, 2013.  This reporting period will determine the hospital market basket update for each hospice in FY 2015.



Annual Payment Update Dates


1/1/2013 – 12/31/2013


FY 2015

  • Structural measure – QAPI with patient care
  • NQF 0209

1/1/2014 –


FY 2016


  • Structural measure – QAPI with patient care
  • NQF 0209

Penalty for Non-Compliance

Any hospice that does not meet the data submission requirements for hospice quality measures will have a reduction in the “market basket update by 2 percentage points” for the following fiscal year.  Hospices should be aware that a reduction of 2 percentage points could result in payment rates that are less than the previous fiscal year.  CMS also notes that “any such reduction will not be cumulative and will not be taken into account in computing the payment amount for subsequent FYs.”

Standardized Patient Level Data Item Set

CMS stated that they have been working on the initial development and testing of a hospice patient-level data item set, which could be used by all hospices in the future to collect and submit standardized data items about each patient admitted to hospice. The collected data could be used for calculating quality measures.

CMS recently concluded a pilot test of a draft item set with nine hospices around the country providing services in various care settings. The main purposes of the pilot were to get a clear understanding of the process of implementation of the item set by the hospices and of the burden experienced by the hospices as they implemented the item set and collected data on patients. CMS also commented that they are “considering a target date for implementation of a standardized hospice data item set as early as CY 2014.”

Additional Measures under Consideration and Standardization of Data Collection

CMS is considering an expansion of the required measures to include some additional measures endorsed by NQF.  The standardized data item set may include data items that support NQF #0209 and any or all of the following endorsed measures that could be considered for future reporting:

  • #1617 Patients Treated with an Opioid who are Given a Bowel Regimen
  • #1634 Pain Screening
  • #1637 Pain Assessment
  • #1638 Dyspnea Treatment
  • #1639 Dyspnea Screening

CMS is considering these measures with data collection to begin in 2015, although a final announcement about these measures will be provided in future rulemaking.

Experience of Care Survey

CMS is considering the future implementation of measures based on an experience of care survey, such as the Family Evaluation of Hospice Care (FEHC).  The use of such a survey could precede or follow the implementation of a standardized patient level data set. CMS projects implementation of the data set and an experience of care survey in succession, rather than concurrently, to avoid excessive burden to hospices.

Public Reporting of Hospice Quality Data

CMS states that “public reporting of quality data is a vital component of a robust quality reporting program and CMS is fully committed to developing the necessary systems for public reporting of hospice quality data.”  No timeline for public reporting of hospice data has been announced, but the development and implementation of a standardized data set for hospice must precede public reporting.  The timeline for public reporting will be announced as future rules are developed.