§ 512.411 - Quality measures and reporting for AMI model.

§ 512.411 Quality measures and reporting for AMI model.

(a) Required measures.

(1) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (NQF #0230) (MORT-30-AMI).

(2) Excess Days in Acute Care after Hospitalization for AMI (AMI Excess Days).

(3) HCAHPS Survey (NQF #0166).

(b) Voluntary measure.

(1) Voluntary Hybrid Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Myocardial Infarction (AMI) Hospitalization (NQF #2473) (Hybrid AMI Mortality).

(2) To be eligible to receive the additional points added to the AMI composite quality score for successful voluntary data submission of clinical electronic health record data, as described in § 512.411(b)(1), AMI model participants must submit the clinical electronic health record data requested by CMS related to each eligible AMI anchor hospitalization during the performance period. The data must be submitted within 60 days of the end of the most recent performance period and be accompanied by the limited risk variable data (five elements finalized) as outlined in § 512.315(b)(1)(iv).

(i) For each eligible AMI anchor hospitalization, all five risk variable data elements are required to be submitted. The five risk variables are as follows:

(A) Age.

(B) First-captured heart rate measured within 2 hours of a patient presenting to the hospital.

(C) First-captured systolic blood pressure measured within 2 hours of a patient presenting to the hospital.

(D) First-captured troponin values measured within 24 hours of a patient presenting to the hospitals.

(E) First-captured creatinine values measured within 24 hours of a patient presenting to the hospitals.

(ii) For each eligible AMI anchor hospitalization, six linking variables are required to merge the electronic health record data with the CMS claims data:

(A) AMI model participant CCN.

(B) Medicare Health Insurance Claim Number.

(C) Sex.

(D) Date of birth.

(E) Admission date.

(F) Discharge date.

(iii) For years 1 through 5 of the AMI model an increasing amount of data are requested by CMS for each performance period as follows:

(A) Year 1. Submit electronic health record data on > 50 percent of eligible AMI anchor hospitalizations between July 1, 2017 and August 31, 2017.

(B) Year 2. Submit electronic health record data on over 90 percent of eligible AMI anchor hospitalizations between September 1, 2017 and June 30, 2018.

(C) Year 3. Submit electronic health record data on over 90 percent of eligible AMI anchor hospitalizations between July 1, 2018 and June 30, 2019.

(D) Year 4. Submit electronic health record data on over 90 percent of eligible AMI anchor hospitalizations between July 1, 2019 and June 30, 2020.

(E) Year 5. Submit electronic health record data on over 90 percent of eligible AMI anchor hospitalizations between July 1, 2020 and June 30, 2021.