Data Validation Overview

Hospitals-Outpatient

Validation is designed to verify that patient-level clinical data submitted by a hospital for the Hospital Outpatient Quality Reporting (OQR) Program are accurate and consistent, based upon the percent agreement between the hospital's and the Centers for Medicare & Medicaid Services (CMS) Clinical Data Abstraction Center’s (CDAC’s) abstraction results. All patient-level data successfully submitted to the Outpatient Prospective Payment System (OPPS) Clinical Warehouse by hospitals subject to Hospital OQR program requirements are subject to the hospital data validation process. Critical Access Hospitals and other hospitals not subject to Hospital OQR program requirements are exempt from the validation process.

Process Defined

For the validation process, CMS selects a random sample of cases from the universe of abstracted data submitted by hospitals selected for validation. Then, CMS requests that hospitals submit copies of the corresponding medical records to the CDAC. The CDAC re-abstracts data for the clinical measures from the records received, comparing its results to the corresponding data previously submitted by the hospital.

Validation for CY 2014 Payment

For the calendar year (CY) 2014 OPPS payment determination, CMS will request medical records beginning with encounter dates of April 1, 2012, from 500 hospitals: 450 randomly selected hospitals and 50 targeted hospitals, with up to 12 records requested per hospital per quarter. The 50 targeted hospitals will be selected based upon either failing the validation requirement or having outlier values in the hospital's submitted data.

To receive the full OPPS annual payment update (APU), the 500 selected hospitals must obtain at least a 75 percent validation score, based upon this validation process, for the designated time period. The validation results will affect the CY 2014 APU for the selected hospitals.

The 500 hospitals (PDF-183 KB) will be required to send in records quarterly for one year. It is possible for a hospital to be selected in consecutive years.

Validation Process

Once the random selection has been completed, the CDAC uses U.S. Postal Service Certified Mail to request supporting medical record documentation that corresponds to each selected case. Hospitals must supply the medical records, in paper format as specified in the requesting letter or another secure and trackable method, for each requested case by the established deadline or risk a 2.0 percent reduction in their APU.

Each hospital must submit this documentation to the CDAC by 4:30 p.m. ET of the date specified in the requesting letter; this date is 45 calendar days from the date of the request. If the hospital fails to comply within 30 days of the initial medical documentation request, the CDAC will send a second certified letter to the hospital, reminding it that the requested documentation must be received within 45 calendar days following the date of the initial request. If the hospital still fails to comply, a “zero” score will be assigned to each data element for each selected case, and the case will fail for all measures in the same topic (for example, OP-6 and OP-7 measures for a surgical care case).

A hospital's list of cases selected for validation each quarter—including all available patient identifiers—can be accessed on My QualityNet by any registered user who has been assigned the HOP QDRP Feedback Reports role. (From the My Tasks page, access Reports > Run; from the Report Category drop-down menu, select Hospital Reporting - Data Validation Reports - Outpatient > Case Selection Report.) Note: This report will be available no later than 7 to 10 days from the date on the CDAC Medical Record Documentation Request.

Once the CDAC receives the requested medical documentation, it independently: 1) re-abstracts the same quality measure data elements that the hospital previously abstracted and submitted; and 2) compares the two sets of data to determine whether they match.

Resources

Sample letters used by the CDAC for the initial request for medical records, the second/final request for medical records, and the instructions for medical records submission are listed below:

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