Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare
The Centers for Medicare & Medicaid Services (CMS) is granting exceptions1 under certain Medicare quality reporting and value-based purchasing programs to providers located in areas affected by the Kentucky severe storms, flooding, landslides, and mudslides 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 Kentucky Severe Storms, Flooding, Landslides, and Mudslides (DR-4663-KY) disaster declarations are located at Designated Areas: Disaster 4663 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), home health agencies (HHAs), hospices, inpatient psychiatric facilities (IPFs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs) and affects the following programs and deadlines noted in the table below.
For the Medicare Promoting Interoperability Program, a Hardship Exception Application is available for eligible hospitals and critical access hospitals (CAHs) affected by the Kentucky Severe Storms, Flooding, Landslides, and Mudslide’s disaster. Please note, however, that in no case may a hospital be granted an exemption for more than 5 years (Social Security Act section 1886(b)(3)(B)(ix)(II)).
End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
Dialysis facilities should note that CMS has not issued exceptions for the ESRD QIP to address the impact of the Kentucky Severe Storms, Flooding, Landslides, and Mudslides. Impacted dialysis facilities should submit Extraordinary Circumstances Exceptions (ECE) requests according to the process and form found on www.QualityNet.cms.gov. Within 90 days of the event, forms should be submitted via email or managed file transfer (MFT) to QRFormsSubmission@HSAG.com, or via secure fax to (877) 789-4443. When sending via MTF, uncheck “Required Registered Users.”
Merit-based Incentive Payment System (MIPS)
The MIPS automatic Extreme and Uncontrollable Circumstances (EUC) policy will be applied at the individual level to MIPS eligible clinicians identified as located in affected counties designated by the FEMA under the Kentucky Severe Storms, Flooding, Landslides, and Mudslides (DR-4663-KY) disaster. For these clinicians, we aim to reduce reporting burden by eliminating the need to submit an application to request reweighting of all MIPS performance categories to receive a neutral payment adjustment. For more information review the 2022 MIPS Automatic EUC Fact Sheet.
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 ECE 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 are submitted, they may be publicly reported or used in scoring.
Please refer to the ECE request process and form specific to the program for additional information.
As noted above, for the Medicare Promoting Interoperability Program, a Hardship Exception Application is available for eligible hospitals and CAHs affected by the Kentucky Severe Storms, Flooding, Landslides, and Mudslides disaster. Please note, however, that in no case may a hospital be granted an exemption for more than 5 years (Social Security Act section 1886(b)(3)(B)(ix)(II)).
 The terminology “exception” is used as a general term intended for ease of reference, to collectively refer to policies established under separate programs, and may not be consistent with the specific terminology established under each individual program.
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 weekdays from 8 a.m. to 8 p.m. ET. For questions regarding technical issues, contact the CCSQ Support Center at QNetSupport@cms.hhs.gov, or by calling, toll-free 866.288.8912 (TTY: 877.715.6222), weekdays from 8 a.m. to 8 p.m. ET.