All Medicare certified hospice agencies must submit an HIS Admission and HIS Discharge record on all admissions and discharges from their agency. The report must include all patients, irrespective of payer source, patient age, or location where hospice services were provided. It is recommended that data is submitted within 14 days to be sure that it is accepted within the required 30 day time frame.  Submitting early will give the hospice agency time to adjust and correction the data, as needed.

What information is included in each HIS record?

• Admission HIS: Captured during the admission process
  • Administrative information
  • Preferences
  • Active diagnoses
  • Health conditions
  • Medications
  • Record administration
• Discharge HIS: sections of information captured during the discharge process
  • Administrative information
  • Service utilization (this has been replaced)
  • Record administration

How are HIS records used?

The HIS record is used to compute seven process measures:

1. Patient treatment preferences
2. Beliefs/values address if desired by the patient
3. Pain screening
4. Pain assessment
5. Dyspnea treatment
6. Dyspnea screening
7. Patients treated with an opioid who are given a bowel regimen

These process measures are combined to compute a single composite quality measure – the Comprehensive Assessment at Admission – that is reported on Care Compare.  This composite measure assesses whether the seven key care processes were followed when a patient was admitted to hospice.

What are HIS Submission requirements?

• Within 30 days of patient admission or discharge of each hospice patient. All HIS records must be successfully accepted by QIES ASAP system within 30 calendar days of the patient admission or discharge date. See here for details on submitting HIS data
• –          The requirements have included an incrementally increasing compliance threshold since data collection began. The Final Rule stated that beginning with FY 2018 reporting year, to avoid the 2 percentage point reduction in Annual Payment Update (APU), hospice agencies were required to submit at least 70% of their required HIS records within the 30 day deadline. For FY 2019 this minimum threshold was increased to 80% of all required HIS records. For FY 2020 and all subsequent years, the minimum threshold was increased to 90% of all required HIS records within the 30 day deadline.   Hospice agencies that meet the submission threshold will avoid the 2% reduction in APU payment.
• –          Non compliant providers, that is – providers that fail to meet this submission threshold, receive notification from CMS via a HQRP non-compliance letter that CMS sends via USPS and via the CASPER system. The CASPER letter identifies why the hospice agency is non-compliant and also provides information on how the hospice agency can request reconsideration. Agencies should monitor CASPER for receipt of such notice; agencies have 30 days from the date that the letter is sent for reconsideration.

How can a hospice agency validate that its HIS data has been accepted?

An agency can use reports in CASPER to monitor the status of HIS records submitted to QIES ASAP and track HIS record status, determine when correction of errors is required. 

• The Hospice Timeliness Compliance Threshold Report enables a hospice agency to check the timeliness of acceptance of HIS records including the percentage of records that were submitted within the 30 day deadline to determine whether the agency will meet the required threshold.
• The Hospice Final Validation Report provides information on the status of submitted HIS files, indicated whether or not the records were accepted and details of any warning or error messages, if generated.

Where can you get more information?

• Calculation of HIS measures, data submission requirements:  CMS HIS information
• NHPCO information on HIS:  HIS details