CMS Reporting FAQ | NHSN (2023) (2023)

Data reporting

Where can I find guidance on what to report to the CMS for my property type?

• More information on reporting required by the NHSN can be found hereNHSN CMS requirements website. This page provides operational guidance, reporting guidance, and analytics explanations for specific types of reporting. For an abbreviated list of reporting requirements by facility type, seeCMSpdf icon reporting requirementsdocument. A more detailed list of reporting requirements and related deadlines can be found inCMS iconpdf reporting requirements and deadlines document. In addition, your local Quality Improvement Organization (QIO) or End-stage Kidney Disease (ESRD) Network can provide more information on what is expected of your facility.

Where can I find the appropriate CMS reporting language for my object type?

• Facilities can find the exact language of the respective CMS reporting program on the CMS website.
  • CMS Hospital Patient Quality Reporting Program (IQR)outdoor icon
  • CMS Hospital Outpatient Quality Reporting (OQR) program.outdoor icon
  • CMS Long Term Care Quality Reporting Program (LTCHQR).outdoor icon
  • CMS Hospital Rehabilitation Facility Quality Reporting Program (IRFQR).outdoor icon
  • CMS End Stage Kidney Disease (ESRD) Quality Improvement Program (QIP)outdoor icon
  • CMS PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR)outdoor icon
  • CMS ambulatory surgery quality reporting programoutdoor icon
  • CMS Inpatient Psychiatric Facility Quality Reporting Program (IPFQR)outdoor icon

Where can I find advice on how to make sure my NHSN facility is set up correctly to report to the CMS?

• Advice on how to set up your NHSN facility to properly submit CMS claims can be found here on the NHSN websiteWebsite with CMS requirements.

I need guidance on how to set up locations in my NHSN facility to comply with CMS reporting. Where can I find this information?

• For information on mapping locations at an NHSN facility, see the NHSN Mapping Locations Adobe PDF.

Where can I obtain a waiver showing that my acute care facility does not meet the CMS reporting requirements?

• Please contact CMS QIOSC to initiate the opt-out process: IQR@hsag.com.

Where can I direct my questions about CMS payments and/or receipts or other questions not related to NHSN reporting?

• For questions regarding payment and/or CMS validation, or any other questions not related to NHSN reporting, please contact the Quality Improvement Organization (QIO), ESRD Network, or CMS directly.

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Data transfer

Do I need to grant permission or join a CMS group to share my CMS data for reporting purposes?

• NO. If the facility has correctly entered its CMS Certification Number (CCN) into the NHSN, has completed the monthly reporting schedules, and entered data accordingly, the data will be automatically uploaded to the CMS for the required reporting programs. QIOs, ESRD Networks or State Departments of Health may ask facilities to join their group for monitoring and assistance, but data will be sent to the CMS whether or not the NHSN facility is a member of such groups.

How does my information get from the NHSN to the CMS?

• The data entered in the NHSN are sent to the CMS in accordance with the object CCN (CMS Certification Number). The CMS provides the CDC with a list of CCNs from which they expect data for the required reports. The CDC then takes that list and pulls the relevant data from each NHSN facility from the CCN on the CMS list. Data "snapshots" are periodically sent to the CMS, but the final data is "frozen" at midnight on the reporting deadline and sent to the CMS on the next business day (e.g., the next business day after the 3rd).

Why do some facility types report rates while others report SIR to the CMS?

• Rates are sent to the CMS when insufficient data has been entered for a particular reporting measure to calculate a baseline. Once sufficient data has been collected to develop appropriate SIR models for these types of locations, CDC will provide SIRs for these measures.

What are the deadlines for submitting data for CMS reporting?

• The deadlines for submitting data to CMS reporting depend on the type of object. A full list can be found here: NHSN reporting requirements and deadlines under current CMS rules Adobe PDF files.

Where can I see what data will be sent to the CMS from my NHSN facility?

• Facilities can view the NHSN data that will be uploaded to the CMS using the specific NHSN analysis output options for their specific type of facility. To find reports relevant to your type of facility, log into your NHSN facility and go to Analyze > Output Options > CMS Reports > CDC Defined Output. Detailed instructions on running and interpreting CMS reports can be found on the NHSN CMS Requirements page.

What if the records on CMS's Hospital Comparison do not match the records I had on NHSN?

• Please note that any data entered or modified within the NHSN after the quarter freeze date will not be reflected in the data published on Hospital Compare. In addition, each quarter's frozen data is aggregated to produce measurements in Hospital Compare. If you still have questions about your facility's HAI data displayed in Hospital Compare, please contact NHSN Help (NHSN@cdc.gov).

Where can I find information on how to verify my details?

• CDC offers guidelines for validating CLABSI, CAUTI, COLO and HYST SSI data and MRSA and CDI LabID data at your facility. The guide is available atNHSN Data Validation website.

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CMS Certificate Numbers (CCN)

My CCN was not validated when I registered my facility with the NHSN. What do I need to do now and how will this affect my CMS reports?

• If your CCN was not verified when you registered your facility with NHSN, you will need to add it to NHSN as soon as your NHSN facility is activated. You can add a CCN on the NHSN Site Information page. To do this, follow these steps:
  • After logging in to an NHSN facility, click on Facility in the left navigation bar. Then click Object Information from the drop-down menu. On the Edit Facility Information page, the first section contains a space for the CMS Certification Number (CCN). Replace N/A with your facility's CCN. After confirming that the CCN is correct, scroll down the page and click the gray Update button. A message should appear at the top of the page confirming the update.
• If your CCN is not entered into the NHSN by the next CMS filing deadline, your details will not be sent to the CMS.
• If your facility is new and you have not yet received a CCN, you can submit your information as needed and add a CCN to your NHSN facility as soon as it becomes available.

I provide the CMS Certification Number (CCN) to the care provider(s). What happens to our data after uploading them to the CMS?

• If more than one facility shares a CCN, data from those facilities is aggregated by the CDC and reported to the CMS at the CCN level. Note: NHSN analysis output options only include data from your NHSN Facility OrgID; therefore these numbers will be different from the ones you see on the CMS pages.

My facility was purchased or merged with another facility and now I have a different CCN. What do I need to do to make sure this change is registered with my NHSN?

• It is important to contact the NHSN for instructions on when to enter a new CCN into the NHSN. Email NHSN Help (NHSN@cdc.gov) for assistance.
• When it's time to add a new CCN to the NHSN, follow these steps:
  • You can change your CCN by following these steps: After logging in to your NHSN facility, click on your facility in the left navigation bar. Then click Object Information from the drop-down menu. On the Edit Facility Information page, the first section contains a space for the CMS Certification Number (CCN). Click on the blue "Edit CCN" hyperlink. In the edit CCN record pop-up window, click the gray Add Row button. After adding a new row, enter the new CCN and effective date. The applicable reporting quarter will be automatically populated based on the effective date you entered. Confirm that the CCN and effective date are correct, then click the gray Save button to save the update. You will see another popup saying your CCN has been successfully created. Click OK to close the pop-up, then click Close on the Edit CCN Records pop-up to complete the change.

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Exercises

What training do I need to complete before I can upload my data?

• If you are a current NHSN user who has already received basic setup and data entry training, the CDC recommends completing HAI training specific to the types of reports you complete each year to stay up to date with updated definitions and protocols. In addition, if you are new to the NHSN system, the CDC recommends that you complete basic facility registration and setup training, as well as data entry and analysis training along with HAI-specific training.

Where can I find training?

• Specific HAI training courses can be found on each specific HAI page on the NHSN website. All courses can also be found on the NHSN Training website.
• Note: the training is not specific to the type of institution. Therefore, all institutions that collect CLABSI data can use the same CLABSI training materials.

My facility is not an intensive care hospital. Do I go through the same training?

• Yes, the workouts are specific to the HAI type only. They are not specific to the object type. For example, all facilities reporting CAUTI data may use the same CAUTI training materials and NHSN protocols.

How often do I need to complete NHSN training?

• The CDC recommends completing the training once a year. Any changes to definitions or protocols made within the NHSN take effect on January 1, so the CDC recommends reviewing NHSN protocols and training at the beginning of each year.

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SAMS (Secure Access Management Services)

Does every NHSN user need their own SAMS credentials?

• Yes. SAMS credentials are user specific, NOT object specific. Therefore, each individual user in the facility must have their own SAMS account and network card. In addition, users who need access to more than one NHSN facility can use the same SAMS credentials for all NHSN accesses. To do this, you must use the same email address at each NHSN facility.

Do I need separate SAMS credentials to access other parts of the NHSN, such as the Health Staff Security Component?

• NO. SAMS credentials are user specific, NOT object or component specific. Once the user has obtained their SAMS credentials, they can access any NHSN component to which they have access rights.

For additional SAMS FAQs, seeSAMS NHSN User FAQ page.

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