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IRF Quality Reporting

IRF Quality Reporting

Section 3004(b) of the Affordable Care Act (ACA) directs the Secretary to establish quality reporting requirements for Inpatient Rehabilitation Facilities (IRFs). Please see below link to text of Section 3004 of the ACA.

A. IRF Quality Reporting
Section 3004 of the ACA requires the Secretary to publish, by no later than October 1, 2012, the selected quality measures that must be reported by IRFs. The ACA requires that CMS use nationally endorsed quality measures, but also allows CMS to specify measures that are not already endorsed if a feasible and practical measure in the area determined appropriate by the Secretary has not been endorsed.

B. Penalties for Failure to Report
For fiscal year 2014, and each subsequent year thereafter, failure to submit required quality data shall result in a 2 percentage point reduction to the annual increase factor for payments made for discharges occurring during that fiscal year.

C. Public Availability of Reported Data
Section 3004 of the ACA requires the Secretary to establish procedures for making the data received as a result of the IRF Quality Reporting Program available to the public and requires the Secretary to establish procedures to ensure that IRFs have the opportunity to review that data prior to public reporting. No date has been specified to begin public reporting of quality data.

To read more about Section 3004 of the ACA (Quality Reporting for Long-Term Care Hospitals, Inpatient Rehabilitation Facilities, and IRF Programs) please use the link below for P.L. Public Law No: 111-148, the Patient Protection and Affordable Care Act.



October 24, 2014

NOTIFICATION:  FY2016 Payment Update Determination: Data Submissions Deadline Extension

The Centers for Medicare and Medicaid Services (CMS) Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) has extended the deadline for quarter 1 (Q1) 2014 quality measure data submitted via the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN).  The new deadline for submissions of quarter 1 (Q1) 2014 NHSN data is November 15, 2014.  Please note that this new deadline aligns with the previously established quarter 2 2014 quality measure data submission deadline, effectively requiring the submission of both quarter 1 2014 NHSN data and all quarter 2 2014 data no later than 11:59:59 p.m. on November 15, 2014. This deadline extension for IRFs is only for quality measure data submitted via the CDC’s NHSN.  CMS strongly encourages all facilities to submit data several days prior to the deadline to allow time to address any submission issues and to provide opportunity to review submissions to ensure data is complete.

For the FY 2016 payment update determination, only data submitted for the following quality measure are affected by the quarter 1 (Q1), 2014 data submission deadline extension:

  • National Health Safety Network (NHSN) Catheter-Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)

Q1: January 1– March 31, 2014:  Quality data collected during this timeframe was originally due on August 15, 2014.  This deadline has now been extended to November 15, 2014.  This extension is only for quality data submitted to CMS via the CDC’s NHSN.

Q2: April 1 – June 30, 2014All quality data collected during this timeframe is to be submitted to CMS no later than 11:59:59 p.m. on November 15, 2014.  This includes data collected using the Quality Indicator section of the IRF-PAI, as well as data submitted to CMS via the CDC’s NHSN.



Please check the IRF QRP Training webpage for an announcement regarding upcoming IRF Training via a Special Open Door Forum (SODF) on Wednesday, October 29, 2014, from 1:00 p.m. -2:30 p.m. E.S.T., including participation instructions.  This training will cover the data collection and submission of the upcoming required quality measures NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF#1716) and NHSN Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717), which IRFs are required to begin reporting as of January 1, 2015.   


May 6, 2014

The training materials for the May 12, 2014 IRF QRP Provider Training have now been posted on the CMS IRF QRP Training webpage.  To access these materials, please select the link titled Training in the upper left-hand corner of this webpage.  The training materials are located under the Downloads section of the webpage. 


April 29, 2014



Monday, May 12, 2014, from 9:00 a.m. until 4:30 p.m. EDT

CMS Central Office Auditorium, Baltimore, MD

Please check the IRF Quality Reporting Training webpage for more details.  The IRF QRP Training webpage is available by selecting the link of the same name in the upper left-hand corner of this webpage. 


To get help with questions related to the IRF Quality Reporting Program Questions, you may use the contact information listed below:

For questions about IRF-PAI data coding or IRF-PAI data submission:

Phone: 1-800-339-9313 or e-mail:

For questions about CAUTI data or submission, NHSN Registration: 


For questions about Quality measure calculation, data submission deadlines, the new pressure ulcer items: