Claims-Based and Hybrid Measure

The Centers for Medicare & Medicaid Services (CMS) uses a variety of data sources to determine the quality of care that Medicare beneficiaries receive.

For the quality of care measure sets listed below, CMS uses Medicare enrollment data and Part A and Part B claims data submitted by hospitals for Medicare fee-for-service patients. (Hospitals are not required to submit additional data for the claims-based measures.) Each measure set is calculated using a separate, distinct methodology and, in some cases, separate discharge periods.

  • CMS Recalibrated PSI Measure – Includes the Patient Safety Indicators (PSIs) measure.
  • Mortality Measures – Includes the condition-specific acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia and stroke measures; and the procedure-specific coronary artery bypass graft (CABG) measure.
  • Hospital Value-Based Purchasing (VBP) Mortality and Complication Measures
  • Readmission Measures – Includes the condition-specific AMI, COPD, HF, pneumonia and stroke measures, the procedure-specific CABG and total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) measures; and the hospital-wide all-cause readmission (HWR) measure.
  • Complication Measure – Includes the procedure-specific risk-standardized THA/TKA complication measure.
  • Medicare Spending Per Beneficiary (MSPB) Measure
  • Payment Measures – Includes the condition-specific AMI, HF, and pneumonia payment measures, as well as the procedure-specific THA/TKA payment measure.
  • Excess Days in Acute Care (EDAC) Measures – Includes the condition-specific AMI, HF and pneumonia EDAC measures.
  • Episode-Based Payment Measures – Includes information regarding procedural episode-based payment measures (Aortic Aneurism Procedure, Cholecystectomy and Common Duct Exploration, and Spinal Fusion) and condition episode-based payment measures (Kidney/Urinary Tract Infection, Cellulitis, and Gastrointestinal Hemorrhage).
  • Hybrid Measure – Includes information regarding the Voluntary Hybrid Hospital-Wide Readmission (HWR) Measure. The Hybrid HWR Measure differs from the claims-based HWR measure as it merges electronic health record (EHR) data elements with claims data to calculate the risk-standardized readmission rate.

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