CMS's New System of Records for the Hospice Quality Reporting Program

by Baker Ober Health Law

On April 8, 2014, CMS published in the Federal Register a “Notice of a New System of Records (SOR).” CMS is establishing a new SOR titled, “Hospice Item Set System” (or HIS). HIS will support the data collection required for the Hospice Quality Reporting Program (HQRP) as mandated by Section 3004(c) of the Patient Protection and Affordable Care Act of 2010 (ACA). Section 3004(c) of the ACA directed the Secretary of HHS to establish a quality reporting program for hospices that collects, compiles, and eventually publishes data measuring the quality of care provided to patients receiving their hospice benefit. The rule goes into effect on May 8, 2014. Comments on the rule are also due May 8, 2014.

As part of the HQRP, all Medicare-certified hospices are required to submit quality data to CMS. Currently, these hospices submit quality data in the form of facility-level quality measures. CMS selects these quality measures for each HQRP cycle. Hospices are notified of the HQRP quality measures, data collection periods, data submission deadlines, and other requirements through the rule making process. The HQRP operates on a cycle that spans three years, and this cycle includes data collection, data submission, and payment impact. For example, for the first reporting cycle, hospices collected data in 2012 and submitted the data by specific deadlines in 2013. This data impacts the Annual Payment Update (APU) for FY 2014. For more information on the HQRP, see CMS’s website at

Under HIS, hospices will be required to submit data not only for Medicare patients, but for non-Medicare patients as well. One of the purposes of HIS is to collect data from the medical record to address symptom management, patient preferences, and care coordination. It will also house data needed for the HQRP, which data CMS will compile and eventually publish.

HIS is intended to confirm that the “appropriate assessments were made and inquiries or concerns were addressed for each patient at the time of admission for the following domains of care: (1) Pain; (2) Respiratory Status; (3) Medications; (4) Patient Preferences; and (5) Beliefs & Values.” CMS will collect seven quality measures – six National Quality Forum (NQF) endorsed quality measures and one modified NQF endorsed measure: (1) Pain Screening; (2) Pain Assessment; (3) Dyspnea Screening; (4) Dyspnea Treatment; (5) Patients Treated With an Opioid who are Given a Bowel Regimen; (6) Treatment Preference; and (7) Beliefs/values addressed.

Beginning July 1, 2014, hospices will be required to submit two HIS records for each admitted patient – a HIS admission record and a HIS discharge record. Hospices have 14 days to complete the HIS admission record and seven days to complete the HIS discharge record, and then have 30 days from admission or discharge to electronically submit the appropriate HIS record to CMS. For more information on HIS, see CMS’s website at

CMS also identified a number of intended routine use disclosures of the collected information, including disclosures to Medicare contractors, as well as government entities with the authority to investigate fraud, waste or abuse.

Ober|Kaler’s Comments

Although the new reporting requirements for hospices go into effect on May 8, 2014, interested providers should still submit comments by the comment deadline, also May 8, 2014, as CMS has stated that it may publish an amended notice in light of submitted comments.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Baker Ober Health Law | Attorney Advertising

Written by:

Baker Ober Health Law

Baker Ober Health Law on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at:

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.