Hospital Harm – Pressure Injury (HH-PI) eCQM

The new eCQM for pressure injuries is here.

Are you ready to start reporting Stage 2 and Deep Tissue Pressure Injuries?

The CMS Hospital Harm – Pressure Injury (HH-PI) eCQM requires hospitals to report all new Stage 2 and Deep Tissue Pressure Injuries (in addition to Stage 3, 4, and Unstageable). While reporting for the eCQM is voluntary in CY 2025, it is scheduled to become MANDATORY in 2028.

WoundVision partners with hospitals across the country to transform pressure injury documentation and streamline surveillance with best in class EMR-integrated workflows, ensuring nothing falls through the cracks.

Check out the information below and access our HH-PI eCQM Calculator to see your estimated performance rate.

ACCESS CALCULATOR

Stage 2/DTPI Inclusion

This eCQM will require hospitals to report all new Stage 2-4, Unstageable and DTPIs.

Mandatory

The HH-PI measure is scheduled to become mandatory.

Lower is Better

A lower score reflects higher quality (the ideal score is 0%).

One PI Per Patient

For patients with multiple new pressure injuries, only one is counted.

Penalty

25% reduction in the market basket update if requirements not met.

RATIONALE

Pressure injuries (PIs) are a serious event and one of the most common patient harms. This safety eCQM captures the number of patients who experience harm in the form of a PI using direct extraction of structured data from the EHR to provide hospitals with reliable and timely measurement of their PI rates.

MEASURE DESCRIPTION

This eCQM assesses the proportion of inpatient hospitalizations for patients ages 18 years and older at the start of the encounter who suffer the harm of developing a new stage 2, stage 3, stage 4, deep tissue, or unstageable PI.

GOAL

By incentivizing hospitals to adopt best practices in PI prevention and treatment, CMS aims to enhance patient safety.

A. DENOMINATOR

The denominator is equal to the initial population.

B. DENOMINATOR EXCLUSIONS

The denominator exclusions represent PIs that were outside of the hospital's control. This includes:

Deep tissue pressure injury (DTPI) found on exam 72 hours or less after the admission
Stage 2, 3, 4 or unstageable PI diagnosis present on admission (POA)
Diagnosis of a COVID-19 infection during the admission

C. NUMERATOR INCLUSIONS

The numerator represents inpatient hospitalizations for patients with a new PI. This includes:

Diagnosis of DTPI not POA or found on exam >72 hours after the admission
Diagnosis of stage 2, 3, 4 or unstageable PI not POA or found on exam >24 hours after the admission

25% Penalty For Improper IQR

The Hospital Inpatient Quality Reporting (IQR) Program is a pay-for-reporting program for acute care hospitals.

If hospitals fail to meet the CMS Inpatient Quality Reporting (IQR) requirements will incur a penalty of 25% to their Market Basket Update (MBU). This applies to reimbursement for all Medicare claims in a given year and compounds over time.

2025 IQR Penalty Example

Your hospital has $110MM in annual Medicare claims revenue
You do not complete all of the IQR requirements
The 2025 MBU is 3.4% (not including productivity adjustment of -0.5%)
25% penalty would result in a 2.05% payment increase versus a 2.9% payment increase
Compounded over 3 years, the resultant financial loss would be ~2.9MM

The new eCQM for pressure injuries is here.

Important Facts