IRF Quality Reporting Program Details

IRFs are required to submit quality data for the IRF Quality Reporting Program beginning on 10/01/2012. During the first year of the IRF Quality Reporting Program, IRFs are required to report data related to two measures: (1) Pressure ulcers that are new or worsened since admission; and (2) CAUTI - Catheter associated urinary tract infections. Additional quality measures will be added for subsequent of the IRF Quality Reporting Program through the rulemaking process. For further details about the ACA Section 3004 IRF Quality Reporting Program, visit the links provided below.

A. Data Submission Updates for the Pressure Ulcer Measure
IRF providers are required to submit their pressure ulcer data as part of the IRF-PAI assessment which must be submitted for each Medicare beneficiary. IRF providers are required to begin use of a new version of the IRF-PAI that has been revised to add Quality Indicator (pressure ulcer) Items. Use of the revised IRF-PAI will begin on 10/01/2012 and it must be used for any Medicare patients that are admitted on or after 10/01/2012. Providers must use the revised IRF-PAI for any patients who are admitted before 10/01/2102 but not discharged until after 10/01/2012.

IRF providers will continue to follow all data submission guidelines that are currently in effect for the IRF-PAI. Please see below links to the IRF-PAI Submission User’s Guide and the IRF-PAI Training Manual. (See specifically Section II titled "Item by Item IRF-PAI Coding Instructions" for IRF-PAI submission deadline details).

B. Data Submission Updates for the CAUTI Measure
Data for the CAUTI measure must be submitted on all IRF patients, regardless of payor source. This data shall be submitted to the CDC via the NHSN website. IRF providers, who have not already registered with NHSN, must do so prior to the start of the data collection period. In some cases, IRF providers who are already registered as an NHSN user may need to take additional registration steps in order to be fully prepared to submit their CMS IRF Quality Reporting Program CAUTI data. Please follow any directions or guidance provided by the CDC. In addition, all IRF providers who have not already done so must complete required NHSN training before they will be allowed to begin submitting their data to the CDC. Please see links below for the NHSN website, which provides further data submission guidance.

IRF providers are expected to follow all data submission guidelines and adhere to all data submission deadlines that are set forth by the CDC for the reporting of CAUTI events. It is important to know that IRF providers will be expected to provide reports to the CDC, even if they have had no CAUTI events during any given reporting period.

C. Data Collection Periods for All IRF Measures
Data collection for the IRF Quality Reporting Program will begin on 10/01/2012. The first data collection period will run from 10/01/2012 to 12/31/2012 and will impact the APU determination for FY2014. Thereafter, data will be collected on a calendar year basis (e.g. – 01/01 to 12/31) beginning on 01/01/2013, unless otherwise specified through the rulemaking or sub-regulatory process.

D. Data Submission Deadlines
IRF providers are required to submit pressure ulcer data for each Medicare beneficiary that has been discharged from their facility. This pressure ulcer data will be submitted via the IRF-PAI. IRFs are required to follow all data submission guidelines and adhere to all data submission deadlines to be in compliance. Information about IRF-PAI reporting guidelines and deadlines can be found in the IRF-PAI Training Manual, Section II and the IRF-PAI Data Submission Users Guide (See links below).

IRF providers are required to submit their CAUTI data via the CDC's NHSH website and must follow all reporting requirements and adhere to all HAI reporting deadlines set forth by the CDC. Information about NHSN guidelines and deadlines can be found at the NHSN website (see links listed below).

E.  Helpdesk Contact Information

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:


F. April 2014

Draft Specifications for the Functional Status Quality Measures for Inpatient Rehabilitation Facilities (Version 2)

This document describes draft specifications for four functional status quality measures for inpatient rehabilitation facilities (IRFs). This work builds on previous work, including the Development and Testing of the Continuity Assessment Record and Evaluation (CARE), the Post-Acute Care Payment Reform Demonstration (PAC PRD), and the Analysis of Crosscutting Medicare Functional Status Quality Metrics Using the Continuity Assessment Record and Evaluation. A Technical Expert Panel (TEP) convened by RTI International was consulted during the development of these measure specifications via one in-person meeting and several conference calls.

A summary of the draft specifications is posted in the “Downloads” section below.

Page Last Modified:
12/01/2021 07:02 PM