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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
c. Patient-Level Reporting for Certain Chart-Abstracted Measures Beginning With FY 2024 Payment Determination and Subsequent Years
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In the FY 2013 IPPS/LTCH PPS final rule 77 FR 53655 through 53657, we finalized that IPFs participating in the IPFQR Program must submit data to the Web-Based Measures Tool found in the Inpatient Psychiatric Facility section of the QualityNet websites secure portal between July 1 and August 15 of each year. We noted that the data input forms within the Quality Net secure portal require submission of aggregate data for each separate quarter. In the FY 2014
IPPS/LTCH PPS final rule, we clarified our intent to require that IPFs submit aggregate data on measures on an annual basis via the Web-Based Measures Tool found in the IPF section of the Quality Net websites secure portal and that the forms available require aggregate data for each separate quarter 78 FR 50899 through 50900. In the FY 2016 IPF PPS final rule 80 FR
46716, we updated our data submission requirements to require facilities to report data for chart-abstracted measures to the Web-Based Measures Tool on an aggregate basis by year, rather than by quarter. Additionally, we discontinued the requirement for reporting by age group. We updated these policies in the FY 2018 IPPS/

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LTCH PPS final rule 82 FR 38472
through 38473 to change the specification of the submission deadline from exact dates to a 45-day submission period beginning at least 30 days following the end of the data collection period.
In the FY 2019 IPF PPS final rule 83
FR 38607, we observed that reporting aggregate measure data increases the possibility of human error, such as making typographical errors while entering data, which cannot be detected by CMS or by data submission systems.
We noted that unlike patient-level data reporting, aggregate measure data reporting does not allow for data accuracy validation, thereby lowering the ability to detect error. We stated that we were considering requiring patientlevel data reporting data regarding each patient included in a measure and whether the patient was included in each numerator and denominator of the measure of IPFQR measure data in the future. We sought public comment on including patient-level data collection in the IPFQR program. Several commenters expressed support for patient-level data collection, observing that it provides greater confidence in the datas validity and reliability. Other commenters recommended that CMS
use a system that has already been tested and used for IPF data reporting or work with IPFs in selecting a system so
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that any selected system would avoid additional burden.
We believe that patient-level data reporting would improve the accuracy of the submitted and publicly reported data without increasing burden. As we considered the current IPFQR measure set, we determined that patient-level reporting of the Hours of Physical Restraint Use HBIPS2, NQF 0640
measure and Hours of Seclusion Use HBIPS3,166 NQF 0641 measure would be appropriate for the numerators of these measures only, because these measures are calculated with a denominator of 1,000 hours rather than a denominator of patients who meet specific criteria for inclusion in the measure. Therefore, we proposed to require reporting patient-level information for the numerators of these measures only. For the remainder of the chart-abstracted measures in the IPFQR
Program we proposed to require patientlevel reporting of the both the numerator and the denominator. Table 7
lists the proposed FY 2023 IPFQR
measure set categorized by whether we would require patient-level data submission through the QualityNet secure portal.
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166 We note that in the FY 2022 IPF PPS proposed rule this incorrectly read HBIPS2 86 FR 19514.
We have corrected it to HBIPS3 here.

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