Thank you for your inquiry regarding CMS1218v2, Hospital Harm - Postoperative Respiratory Failure (HH-RF). Submission of American Society of Anesthesiologists (ASA) physical status classification results is important for this measure, as ASA class is a key component of the risk adjustment model. Inclusion of ASA classification results improves the model’s ability to account for patient severity, particularly for patients in higher-risk categories (ASA classes 3–5). When ASA physical status classification results are not submitted, patient severity may be underestimated, which can affect the accuracy of risk-adjusted outcomes. In other words, missing data means the risk adjustment model cannot adjust for the patient's true sickness level, and when high-risk patients are not properly risk-adjusted, this could negatively impact a hospital's quality performance scores. However, ASA classification is one of multiple inputs used for risk adjustment. The HH-RF eCQM also includes 14 additional risk factors, including eight encounter diagnosis-based risk factors and six vital sign-based risk factors. These risk factors contribute to estimating the patient’s probability of experiencing postoperative respiratory failure and support fair comparisons across hospitals treating patients with varying levels of acuity. More information on the different variables included in the measure's risk adjustment model, as well as the probit coefficient for each variable, can be found in the measure's risk adjustment summary report, located on the eCQI Resource Center: https://ecqi.healthit.gov/sites/default/files/RA_PRF_CMS1218_v1.pdf