Centers For Medicare & Medicaid Services (Cms) Inpatient Prospective Payment System (Ipps) Quality Reporting Programs

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Centers for Medicare & Medicaid Services (CMS)
Inpatient Prospective Payment System (IPPS) Quality Reporting Programs
Measure Exception Form for PC, ED, and HAI Data Submission
This Measure Exception Form must be renewed at least annually.
This Measure Exception Form may be used for the following measures: Perinatal Care
(PC-01), Emergency Department (ED-1 and ED-2), and Healthcare-Associated Infection
[Surgical Site Infection (SSI), Catheter-Associated Urinary Tract Infection (CAUTI),
Central Line-Associated Bloodstream Infection (CLABSI)]. This form may be used by
the following programs: Hospital Inpatient Quality Reporting (IQR), Hospital Value-
Based Purchasing (VBP), and Hospital-Acquired Condition (HAC) Reduction.
Fields marked with an asterisk (*) are required.
Specify the applicable quarter(s) for the Measure Exception request(s).
*IPPS Measure Exception Information (select all that apply)
Perinatal Care (PC-01: Elective Delivery Prior to 39 Completed Weeks Gestation)
Hospital has no Obstetrics Department and does not deliver babies.
Calendar Year (YYYY) ________
January 1 through March 31
April 1 through June 30
July 1 through September 30
October 1 through December 31
Emergency Department (ED-1: Median Time from ED Arrival to ED Departure for
Admitted ED Patients and ED-2: Admit Decision Time to ED Departure Time for Admitted
Patients)
Hospital has no Emergency Department and does not provide emergency care.
Calendar Year (YYYY) ________
January 1 through March 31
April 1 through June 30
July 1 through September 30
October 1 through December 31
Specified Colon and Abdominal Hysterectomy Surgical Procedures
Only hospitals that performed 9 or fewer of any of the specified colon and abdominal
hysterectomy combined in the calendar year prior to the reporting year are eligible for
the SSI Measure Exception.
SSI – Colon Surgery (SSI-Colon and SSI-Abdominal Hysterectomy)
Hospital performed a combined total of 9 or fewer colon surgeries and abdominal
hysterectomies in the calendar year prior to the reporting year.
Calendar Year prior to reporting year (YYYY)
_______
Number of procedures performed
_____
Exclusion requested for Calendar Year (YYYY)
_______
December 2015
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