Reporting Exception Granted Due to Texas Severe Winter Storms

2021-4-16

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions1 under certain Medicare quality reporting and value-based purchasing programs located in areas affected by the Texas Severe Winter Storm to assist these providers while they direct their resources toward caring for their patients and repairing structural damages to facilities.

Affected counties designated by the Federal Emergency Management Agency (FEMA) under the Texas Severe Winter Storm (DR-4586-TX) disaster declarations are located at Designated Areas: Disaster 4586 under sections Public Assistance PA-A and PA-B of the FEMA website. If FEMA expands the current emergency disaster declarations to include additional counties, sections PA-A and PA-B will be updated to reflect the newly designated counties

This exception is for acute care hospitals, ambulatory surgical centers (ASCs), Prospective Payment System (PPS)-exempt Cancer Hospitals (PCHs), inpatient psychiatric facilities (IPFs), inpatient rehabilitation facilities (IRFs), Long-Term Care Hospitals (LTCHs), and skilled nursing facilities (SNFs). To see a detailed table of affected programs and deadlines please refer to CMS email 2021-42-IP.

End-Stage Renal Disease Quality Incentive Program (ESRD QIP)

Dialysis facilities should note that CMS has not issued exceptions for ESRD QIP to address the impact of the Texas Severe Winter Storm due to the current suspension of clinical data submission requirements. Impacted dialysis facilities should submit ECE requests according to the process and form found on www.QualityNet.cms.gov. Forms should be submitted to esrdqip@cms.hhs.gov within 90 days of the event.

Extraordinary Circumstances Exceptions (ECE)

Providers located outside the counties listed in the FEMA disaster declaration are not covered by this communication, but they may request an exception to the reporting requirements under one or more Medicare quality reporting or value-based purchasing programs they participate in using the applicable ECE procedure for the respective program(s). In addition, providers located within a county listed in the FEMA disaster declaration who seek an exception for a reporting requirement not covered by this communication may request an individual exception using the applicable ECE procedure for the respective program(s). CMS will assess and decide upon each extraordinary circumstances exception request on a case-by-case basis. 

Hospitals should be aware of the potential impact to reporting requirements and payment programs when deciding whether or not to report data included in the exceptions. If data is submitted, it may be publicly reported or used in scoring.

Please refer to the ECE request process and form specific to the program for additional information.

ProgramECE Email Contact for InquiriesWebsite link to ECE Information
Hospital Quality Reporting Programs (IQR, IPFQR, PCHQR, HVBP, ASCQR, OQR, HACRP, HRRP, Validation)QRFormsSubmission@hsag.comHospital Quality Reporting (HQR) ECE Information
ESRD QIPESRDQIP@cms.hhs.govEnd Stage Renal Disease Facilities / ESRD Quality Incentive Program (QIP) / Information
SNF VBPSNFVBPinquires@cms.hhs.govSkilled Nursing Facility Value-Based Purchasing (SNF VBP) Program ECE Information
Promoting Interoperability (PI) Program for Hospitalsqnetsupport@hcqis.orgPromoting Interoperability (PI) ECE Information
MIPS/Quality Payment Program (QPP)qpp@cms.hhs.govQuality Payment Program (QPP)
Quality Payment Program (QPP) Resource Center
IRFIRFQRPReconsiderations@cms.hhs.govInpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) ECE Information
LTCHLTCHQRPReconsiderations@cms.hhs.govLong-Term Care Hospital (LTCH) Quality Reporting Program (QRP) ECE Information
SNFSNFQRPReconsiderations@cms.hhs.govSkilled Nursing Facility (SNF) ECE Information
Home HealthHHAPUreconsiderations@CMS.hhs.govHome Health Quality Reporting (HHQR) Program ECE Information
HospiceHospiceQRPReconsiderations@cms.hhs.govHospice Quality Reporting Program ECE Information

Additional information regarding CMS' response to the Texas winter storms is located at https://www.cms.gov/newsroom/press-releases/cms-offers-comprehensive-support-state-texas-combat-winter-storm.

For assistance regarding the information contained in this message, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Team at https://cmsqualitysupport.servicenowservices.com/qnet_qa, or (844) 472-4477. For questions regarding technical issues, contact the QualityNet Help Desk at: qnetsupport@hcqis.org.

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