Hospice Item Set (HIS)  HIS is a patient level data collection tool developed by CMS.  Hospices are required to submit an HIS-­Admission record and an HIS­-Discharge record for each patient no matter their payer source.

HIS compliance

      • The threshold for HIS is 90%. This means that 90% of all HIS assessments must be submitted and accepted within 30 days of the admission or discharge date. The 90% threshold began with calendar year 2018 data for FY 2020 payment impact to the APU and must be met for all subsequent calendar years (CY) for their related FY payment impact.
      • Timely submission alone does not equal compliance.
      • Data must also be accepted. Hospices should submit data within 7-14 days to be sure of acceptance by the 30-day deadline.
      • CMS resource: Timeliness Compliance Threshold Fact Sheet (Aug 2016)

Current HIS measures:

      • Patient Treated with an Opioid who are Given a Bowel Regimen (NQF #1617)
      • Pain Screening (NQF #1634)
      • Pain Assessment (NQF #1637)
      • Dyspnea Treatment (NQF #1638)
      • Dyspnea Screening (NQF #1639)
      • Treatment Preferences (NQF #1641)
      • Beliefs/Values Addressed (If Desired by the Patient) (NQF #1647)
      • Hospice Visits when Death is Imminent – Measure 1: Percentage of patients receiving at least one visit from registered nurses, physicians, nurse practitioners, or physician assistants in the last 3 days of life.
      • Hospice and Palliative Care Composite Process Measure – Comprehensive Assessment at Admission (NQF #3235)

CMS resources

HIS Correction Timeframe

      • Beginning January 1, 2019, hospices will have approximately 4.5 months following the end of each calendar year (CY) quarter to review and correct their HIS records with target dates (i.e., the patient’s admission or discharge date) in that quarter for the purposes of public reporting.
      • Specifically, each data correction deadline will occur on the 15th of the CY month that is approximately 4.5 months after the end of each CY quarter.
      • Providers are encouraged to review their data prior to the data correction deadline for public reporting using their Certification and Survey Provider Enhanced Reports (CASPER) Hospice-Level Quality Measure Report and Hospice Patient Stay-Level Quality Measure Report (QM Reports).
          • These reports are on-demand and thus enable hospice providers to view and compare their performance to the national average for a reporting period of their choice.
      • CMS resource: Policy Update: 4.5 Month Data Correction Deadline for Public Reporting

Important CASPER Reports Related to HIS

The CASPER Reporting application enables a provider to connect electronically to the National Reporting Database. It contains a variety of useful reports for hospice providers.  The following are just a few important reports to help providers monitor their HQRP compliance.

      • Hospice Timeliness Compliance Threshold Report – The Hospice Timeliness Compliance Threshold report summarizes the number and percentage of HIS records submitted within the 30-day submission deadline for the Annual Payment Update (APU) determination.
      • Hospice Final Validation – provides detailed information about the status of the select submission files.
          • The report indicates whether the records submitted in each were accepted or rejected and details the warning messages and fatal errors encountered.
          • The ASAP system-generated final validation report is automatically purged from the Validation Report (VR) folder after 60 days.  The Hospice Final Validation report can be requested if the system-generated report is removed from the system before it could be printed.
      • Hospice-Level Quality Measure Report – The Hospice-Level Quality Measure Report provides hospice-level quality measure values for a select period. Hospice quality measure values are compiled from Hospice Item Set (HIS) data submitted to the National Submissions Database.
      • Hospice Review and Correct Report – The Hospice Review and Correct Report allows hospices to review their quality measure (QM) data to identify if any corrections or changes are necessary prior to the quarter’s data submission deadline, which is 4.5 months after the end of the quarter.

CMS Resource: CASPER – Hospice Reporting User’s Guide