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2025 IPPS Proposed Rule
Proposed Major Changes from the 2025 IPPS Proposed Rule
© Medisolv, Inc. All Rights Reserved | 2
IQR Program
eCQMs
© Medisolv, Inc. All Rights Reserved | 4
Changes to the IQR Program
CMS is proposing to move hospitals from 4 required eCQMs (2023), to 6 (2024), to 9 (2026), to 11
(2027).
© Medisolv, Inc. All Rights Reserved | 5
eCQMs
ADDING HOSPITAL HARM MEASURES
The new required eCQMs are all around Hospital Harm (Patient Safety)
© Medisolv, Inc. All Rights Reserved | 6
6
Total eCQMs Reported
CY 2024/FY 2026 and
CY 2025/FY 2027
Three self-selected eCQMs; and
1. Safe Use of Opioids - Concurrent
Prescribing
2. Cesarean Birth
3. Severe Obstetric Complications
Required eCQMs
to be Reported
Reporting Period/ Payment Determination
1.
2.
3.
© Medisolv, Inc. All Rights Reserved | 7
9
Total eCQMs Reported
CY 2026/FY 2028
Three self-selected eCQMs; and
1. Safe Use of Opioids - Concurrent
Prescribing
2. Cesarean Birth
3. Severe Obstetric Complications
4. Hospital Harm - Severe
Hyperglycemia
5. Hospital Harm - Severe
Hypoglycemia
6. Hospital Harm - Opioid-Related
Adverse Events
Required eCQMs
to be Reported
Reporting Period/ Payment Determination
1.
2.
3.
4.
5.
6.
© Medisolv, Inc. All Rights Reserved | 8
11
Total eCQMs Reported
CY 2027/FY 2029
Three self-selected eCQMs; and
1. Safe Use of Opioids - Concurrent
Prescribing
2. Cesarean Birth
3. Severe Obstetric Complications
4. Hospital Harm - Severe
Hyperglycemia
5. Hospital Harm - Severe
Hypoglycemia
6. Hospital Harm - Opioid-Related
Adverse Events
7. Hospital Harm - Pressure Injury
8. Hospital Harm - Acute Kidney
Injury
Required eCQMs
to be Reported
Reporting Period/ Payment Determination
1.
2.
3.
4.
5.
6.
7.
8.
© Medisolv, Inc. All Rights Reserved | 9
eCQMs
ADDITIONAL MEASURES
In addition, they are rolling out two more eCQMs (though not required yet).
 Hospital Harm – Falls with Injury eCQM (available in 2026)
 Hospital Harm – Post-operative Respiratory Failure eCQM (available in
2026)
© Medisolv, Inc. All Rights Reserved | 10
HOSPITAL HARM
Falls with Injury eCQM
• Available 2026
• This is a brand-new measure
that assesses the number of
inpatient hospitalizations where
at least one fall with a major or
moderate injury occurs for
patients age 18 years and older.
© Medisolv, Inc. All Rights Reserved | 11
HOSPITAL HARM
Post-Operative Respiratory
Failure eCQM
• Available 2026
• This is a brand-new measure
that assesses the number of
elective inpatient hospitalizations
for patients aged 18 years and
older without an obstetrical
condition who have a procedure
resulting in postoperative
respiratory failure (PRF) within
30 days of first OR procedure.
Structural Measures
© Medisolv, Inc. All Rights Reserved | 13
Structural Measures
ADDITIONAL STRUCTURAL MEASURES
CMS is proposing to require submission of two new Structural measures in 2025.
Both measures work just like the HCHE measure with 5 domains that you
must positively attest yes to all 5 domains to earn full credit for these
measures.
Patient Safety
Structural measure
Age Friendly Hospital
Structural measure
Claims Measures
© Medisolv, Inc. All Rights Reserved | 15
Claims Measures
ADDITIONAL CLAIMS MEASURE
CMS is proposing to replace the PSI-04 Claims measure with a new claims measure.
Beginning with the July 1, 2023 – June 30, 2025 reporting period, which
impacts the FY 2027 payment determination.
Thirty-day Risk-Standardized Death
Rate among Surgical Inpatients with
Complications (Failure-to-Rescue)
claims-based measure
© Medisolv, Inc. All Rights Reserved | 16
AMI Payment HF Payment PN Payment THA/TKA Payment
Hospital-level, Risk-
Standardized Payment
Associated with a
30-Day Episode of
Care for Acute
Myocardial Infarction
Hospital-level, Risk-
Standardized Payment
Associated with a
30-Day Episode of
Care for Heart Failure
Hospital-level, Risk-
Standardized Payment
Associated with a
30-Day Episode of Care
for Pneumonia
Hospital-level, Risk-
Standardized Payment
Associated with a 30-day
Episode of Care for
Elective Primary Total Hip
Arthroplasty and/or Total
Knee Arthroplasty
CMS is also proposing to remove the 4 payment claims measures and replace them
with the Medicare Spending per Beneficiary (MSPB) measure.
Claims Measures
1 2 3 4
NHSN HAI Measures
© Medisolv, Inc. All Rights Reserved | 18
NHSN HAI Measures
ADDITIONAL NHSM HAI MEASURES
CMS is proposing to add two new mandatory NHSN healthcare-associated
infection (HAI) measures.
Both beginning in Calendar Year 2026 reporting period
Catheter-Associated Urinary
Tract Infection (CAUTI)
Standardized Infection Ratio
Stratified for Oncology
Locations measure
Central Line-Associated
Bloodstream Infection
Standardized Infection (CLABSI)
Ratio Stratified for Oncology
Locations measure
© Medisolv, Inc. All Rights Reserved | 19
COVID-19 and Immunization Reporting
Replacing COVID-19 and Immunization reporting with new process.
Beginning on October 1, 2024, hospitals and CAHs would have to
electronically report certain data elements about COVID-19, influenza, and
respiratory syncytial virus (RSV) on a weekly basis.
• Information includes confirmed infections of respiratory illnesses, including
COVID-19, influenza, and RSV, among hospitalized patients
• Hospital bed census and capacity
• Limited patient demographic information, including age.
HCHAPS Measures
© Medisolv, Inc. All Rights Reserved | 21
HCHAPS
ADDITIONAL HCHAPS SUB-MEASURES
Three new sub-measures:
• These three new sub-measures would be publicly reported beginning in October 2026.
• Remove “Care Transition” reporting on Care Compare in January 2026.
• Additionally, the current “Responsiveness of Hospital Staff” sub-measure would be
altered starting in January 2025, with the “Call Button” questions being removed from
the survey and a new “Get Help” question being added.
Care Coordination
Restfulness of Hospital
Environment
Information about
Symptoms
Proposed Changes to the
Auditing Process
© Medisolv, Inc. All Rights Reserved | 23
Auditing Process
PROPOSED CHANGES
CMS is proposing to modify the current data validation (audit) scoring to
implement two separate validation scores, one for clinical processes of care
(CPoC) measures and one for eCQMs, and equally weighting them at 50%
each.
Previously, eCQM validation was weighted at zero to give hospitals time to
gain experience with eCQM reporting and validation.
Promoting Interoperability Program
© Medisolv, Inc. All Rights Reserved | 25
Promoting Interoperability Program
PI PROGRAM MODIFICATIONS
CMS is proposing to modify the PI program with basically every change from
the IQR program. In addition, they are splitting out the Antimicrobial Use and
Resistance (AUR) Surveillance measure into two measures.
• Beginning in 2025.
• CMS is also proposing to increase the scoring threshold from 60 points to 80
points starting in 2025.
Antimicrobial Use
(AU) Surveillance
Antimicrobial Resistance
(AR) Surveillance
Hospital Value-Based Purchasing
(HVBP) Program
© Medisolv, Inc. All Rights Reserved | 27
Patient Safety
Structural
HCAHPS
Survey
Hospital Commitment to
Health Equity
Adopt the Patient
Safety Structural
measure beginning in
Calendar Year 2025
Modify the HCAHPS
Survey measure
beginning in Calendar
Year 2025
Move up the start date
for publicly displaying
hospital performance on
the Hospital Commitment
to Health Equity measure
to January 2026
CMS is proposing three changes to the HVBP program.
HVBP Program
1 2 3
TEAM Model
Transforming Episode Accountability Model
© Medisolv, Inc. All Rights Reserved | 29
The episodes they are testing are:
Which they are pairing with these quality measures:
TEAM Model
CABG LEJR
Major Bowel
Procedure
SHFF
T
Spinal Fusion
(For all episodes) Hybrid
Hospital-Wide All-Cause
Readmission Measure
(For all episodes) PSI 90
(For LEJR episodes only)
THA/TKA PRO-PM (Inpatient)
Year 1 = July 1, 2024 – June 30, 2025 Year 1 = July 1, 2023 – June 30, 2025 Year 1 = July 1, 2024 – June 30, 2025
CMS is proposing a brand-new bundled payment
model which is mandatory for hospitals starting
January 1, 2026 through December 31, 2030. The
model pairs episode-based pricing linked to quality
measure performance.
© Medisolv, Inc. All Rights Reserved | 30
TEAM Model
TEAM is mandatory for acute care hospital who bills for these episodes, are paid
under the IPPS, has a CMS Certification Number (CCN), and has a primary
address located in one of the 800 geographic areas selected for participation in
TEAM.
© Medisolv, Inc. All Rights Reserved | 31
TEAM Model
In this new model you could make or lose money (for those episodes) based
on how well you perform on those quality measures and how much you spent.
Year 1 you get only an upside for good performance, after that you could gain
or lose money based on those factors.
Medisolv
© 2024 Medisolv, Inc. All rights reserved.
www.medisolv.com | info@medisolv.com | (844) 633-4765

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2025 Inpatient Prospective Payment System (IPPS) Proposed Rule

  • 1. 2025 IPPS Proposed Rule Proposed Major Changes from the 2025 IPPS Proposed Rule
  • 2. © Medisolv, Inc. All Rights Reserved | 2 IQR Program
  • 4. © Medisolv, Inc. All Rights Reserved | 4 Changes to the IQR Program CMS is proposing to move hospitals from 4 required eCQMs (2023), to 6 (2024), to 9 (2026), to 11 (2027).
  • 5. © Medisolv, Inc. All Rights Reserved | 5 eCQMs ADDING HOSPITAL HARM MEASURES The new required eCQMs are all around Hospital Harm (Patient Safety)
  • 6. © Medisolv, Inc. All Rights Reserved | 6 6 Total eCQMs Reported CY 2024/FY 2026 and CY 2025/FY 2027 Three self-selected eCQMs; and 1. Safe Use of Opioids - Concurrent Prescribing 2. Cesarean Birth 3. Severe Obstetric Complications Required eCQMs to be Reported Reporting Period/ Payment Determination 1. 2. 3.
  • 7. © Medisolv, Inc. All Rights Reserved | 7 9 Total eCQMs Reported CY 2026/FY 2028 Three self-selected eCQMs; and 1. Safe Use of Opioids - Concurrent Prescribing 2. Cesarean Birth 3. Severe Obstetric Complications 4. Hospital Harm - Severe Hyperglycemia 5. Hospital Harm - Severe Hypoglycemia 6. Hospital Harm - Opioid-Related Adverse Events Required eCQMs to be Reported Reporting Period/ Payment Determination 1. 2. 3. 4. 5. 6.
  • 8. © Medisolv, Inc. All Rights Reserved | 8 11 Total eCQMs Reported CY 2027/FY 2029 Three self-selected eCQMs; and 1. Safe Use of Opioids - Concurrent Prescribing 2. Cesarean Birth 3. Severe Obstetric Complications 4. Hospital Harm - Severe Hyperglycemia 5. Hospital Harm - Severe Hypoglycemia 6. Hospital Harm - Opioid-Related Adverse Events 7. Hospital Harm - Pressure Injury 8. Hospital Harm - Acute Kidney Injury Required eCQMs to be Reported Reporting Period/ Payment Determination 1. 2. 3. 4. 5. 6. 7. 8.
  • 9. © Medisolv, Inc. All Rights Reserved | 9 eCQMs ADDITIONAL MEASURES In addition, they are rolling out two more eCQMs (though not required yet).  Hospital Harm – Falls with Injury eCQM (available in 2026)  Hospital Harm – Post-operative Respiratory Failure eCQM (available in 2026)
  • 10. © Medisolv, Inc. All Rights Reserved | 10 HOSPITAL HARM Falls with Injury eCQM • Available 2026 • This is a brand-new measure that assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs for patients age 18 years and older.
  • 11. © Medisolv, Inc. All Rights Reserved | 11 HOSPITAL HARM Post-Operative Respiratory Failure eCQM • Available 2026 • This is a brand-new measure that assesses the number of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF) within 30 days of first OR procedure.
  • 13. © Medisolv, Inc. All Rights Reserved | 13 Structural Measures ADDITIONAL STRUCTURAL MEASURES CMS is proposing to require submission of two new Structural measures in 2025. Both measures work just like the HCHE measure with 5 domains that you must positively attest yes to all 5 domains to earn full credit for these measures. Patient Safety Structural measure Age Friendly Hospital Structural measure
  • 15. © Medisolv, Inc. All Rights Reserved | 15 Claims Measures ADDITIONAL CLAIMS MEASURE CMS is proposing to replace the PSI-04 Claims measure with a new claims measure. Beginning with the July 1, 2023 – June 30, 2025 reporting period, which impacts the FY 2027 payment determination. Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications (Failure-to-Rescue) claims-based measure
  • 16. © Medisolv, Inc. All Rights Reserved | 16 AMI Payment HF Payment PN Payment THA/TKA Payment Hospital-level, Risk- Standardized Payment Associated with a 30-Day Episode of Care for Acute Myocardial Infarction Hospital-level, Risk- Standardized Payment Associated with a 30-Day Episode of Care for Heart Failure Hospital-level, Risk- Standardized Payment Associated with a 30-Day Episode of Care for Pneumonia Hospital-level, Risk- Standardized Payment Associated with a 30-day Episode of Care for Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty CMS is also proposing to remove the 4 payment claims measures and replace them with the Medicare Spending per Beneficiary (MSPB) measure. Claims Measures 1 2 3 4
  • 18. © Medisolv, Inc. All Rights Reserved | 18 NHSN HAI Measures ADDITIONAL NHSM HAI MEASURES CMS is proposing to add two new mandatory NHSN healthcare-associated infection (HAI) measures. Both beginning in Calendar Year 2026 reporting period Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratio Stratified for Oncology Locations measure Central Line-Associated Bloodstream Infection Standardized Infection (CLABSI) Ratio Stratified for Oncology Locations measure
  • 19. © Medisolv, Inc. All Rights Reserved | 19 COVID-19 and Immunization Reporting Replacing COVID-19 and Immunization reporting with new process. Beginning on October 1, 2024, hospitals and CAHs would have to electronically report certain data elements about COVID-19, influenza, and respiratory syncytial virus (RSV) on a weekly basis. • Information includes confirmed infections of respiratory illnesses, including COVID-19, influenza, and RSV, among hospitalized patients • Hospital bed census and capacity • Limited patient demographic information, including age.
  • 21. © Medisolv, Inc. All Rights Reserved | 21 HCHAPS ADDITIONAL HCHAPS SUB-MEASURES Three new sub-measures: • These three new sub-measures would be publicly reported beginning in October 2026. • Remove “Care Transition” reporting on Care Compare in January 2026. • Additionally, the current “Responsiveness of Hospital Staff” sub-measure would be altered starting in January 2025, with the “Call Button” questions being removed from the survey and a new “Get Help” question being added. Care Coordination Restfulness of Hospital Environment Information about Symptoms
  • 22. Proposed Changes to the Auditing Process
  • 23. © Medisolv, Inc. All Rights Reserved | 23 Auditing Process PROPOSED CHANGES CMS is proposing to modify the current data validation (audit) scoring to implement two separate validation scores, one for clinical processes of care (CPoC) measures and one for eCQMs, and equally weighting them at 50% each. Previously, eCQM validation was weighted at zero to give hospitals time to gain experience with eCQM reporting and validation.
  • 25. © Medisolv, Inc. All Rights Reserved | 25 Promoting Interoperability Program PI PROGRAM MODIFICATIONS CMS is proposing to modify the PI program with basically every change from the IQR program. In addition, they are splitting out the Antimicrobial Use and Resistance (AUR) Surveillance measure into two measures. • Beginning in 2025. • CMS is also proposing to increase the scoring threshold from 60 points to 80 points starting in 2025. Antimicrobial Use (AU) Surveillance Antimicrobial Resistance (AR) Surveillance
  • 27. © Medisolv, Inc. All Rights Reserved | 27 Patient Safety Structural HCAHPS Survey Hospital Commitment to Health Equity Adopt the Patient Safety Structural measure beginning in Calendar Year 2025 Modify the HCAHPS Survey measure beginning in Calendar Year 2025 Move up the start date for publicly displaying hospital performance on the Hospital Commitment to Health Equity measure to January 2026 CMS is proposing three changes to the HVBP program. HVBP Program 1 2 3
  • 28. TEAM Model Transforming Episode Accountability Model
  • 29. © Medisolv, Inc. All Rights Reserved | 29 The episodes they are testing are: Which they are pairing with these quality measures: TEAM Model CABG LEJR Major Bowel Procedure SHFF T Spinal Fusion (For all episodes) Hybrid Hospital-Wide All-Cause Readmission Measure (For all episodes) PSI 90 (For LEJR episodes only) THA/TKA PRO-PM (Inpatient) Year 1 = July 1, 2024 – June 30, 2025 Year 1 = July 1, 2023 – June 30, 2025 Year 1 = July 1, 2024 – June 30, 2025 CMS is proposing a brand-new bundled payment model which is mandatory for hospitals starting January 1, 2026 through December 31, 2030. The model pairs episode-based pricing linked to quality measure performance.
  • 30. © Medisolv, Inc. All Rights Reserved | 30 TEAM Model TEAM is mandatory for acute care hospital who bills for these episodes, are paid under the IPPS, has a CMS Certification Number (CCN), and has a primary address located in one of the 800 geographic areas selected for participation in TEAM.
  • 31. © Medisolv, Inc. All Rights Reserved | 31 TEAM Model In this new model you could make or lose money (for those episodes) based on how well you perform on those quality measures and how much you spent. Year 1 you get only an upside for good performance, after that you could gain or lose money based on those factors.
  • 32. Medisolv © 2024 Medisolv, Inc. All rights reserved. www.medisolv.com | info@medisolv.com | (844) 633-4765