Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information

Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information

The purpose of this webpage is to provide information on the measures reported by IRFs in accordance with the IRF QRP. On this page, you will find descriptions of each measure, links to measure specifications, measure updates, and other measure-related information. This page is updated as measure updates become available.

What are the IRF QRP measures?

Measures adopted for and removed from the IRF QRP are listed below. Several are endorsed by the National Quality Forum (NQF), a consensus-based entity contracted by the Secretary to guide the selection of performance measures for federal health programs. Data for the IRF QRP measures are collected and submitted through three methods:

  • Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
  • Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
  • Medicare Fee-For-Service Claims

IRF-PAI Assessment-Based Measures

Data collected using the IRF-PAI and submitted to the Centers for Medicare & Medicaid Services (CMS) via the Internet Quality Improvement and Evaluation System (iQIES):

IRF QRP Measure #1: Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47096 through 47100). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #2: Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47100 through 47111). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #3: IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients (NQF #2633)

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (47111 through 47117). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #4: IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47117 through 47118). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #5: IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47118 through 47119). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #6: IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47119 through 47120). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #7: Drug Regimen Review Conducted with Follow-Up for Identified Issues–PAC IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52111 through 52116). Data collection for this measure began on October 1, 2018.

IRF QRP Measure #8: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

This measure was finalized in the FY 2018 IRF PPS Final Rule, which was published on August 3, 2017 (82 FR 36278 through 36283). Data collection for this measure began on October 1, 2018. This measure replaced Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678).

IRF QRP Measure #9: Transfer of Health Information to the Provider–Post-Acute Care

This measure was finalized in the FY 2020 IRF PPS Final Rule, which was published in the Federal Register on August 08, 2019 (84 FR 39100 through 39105). Data collection for this measure begins on October 1, 2022.

IRF QRP Measure #10: Transfer of Health Information to the Patient–Post-Acute Care

This measure was finalized in the FY 2020 IRF PPS Final Rule, which was published in the Federal Register on August 08, 2019 (84 FR 39105 through 39107). Data collection for this measure begins on October 1, 2022.

For more detailed information on data collection and submission deadlines, please refer to the IRF QRP Data Submission Deadlines webpage. For more information on the data sets and guidance related to the collection and reporting of assessment data, please refer to the IRF-PAI assessment instrument and specifically Chapter 2 of the IRF-PAI Manual located on the IRF-PAI and IRF-PAI Manual webpage.

CDC NHSN Measures

Data for these measures are submitted via the CDC’s NHSN:

IRF QRP Measure #11: National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138)

This measure was finalized in the Calendar Year (CY) 2013 Hospital Outpatient PPS Final Rule, which was published in the Federal Register on November 15, 2012 (77 FR 68504 through 68505). Data submission for this measure began on October 1, 2012.

IRF QRP Measure #12: National Healthcare Safety Network (NHSN) Influenza Vaccination among Healthcare Personnel (NQF #0431)

This measure was finalized in the FY 2014 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2013 (78 FR 47905 through 47906). Data submission for this measure began on October 1, 2014.

IRF QRP Measure #13: National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure (NQF #1717)

This measure was finalized in the FY 2015 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2014 (79 FR 45913 through 45914). Data submission for this measure began on January 1, 2015.

IRF QRP Measure #14: COVID-19 Vaccination Coverage among Healthcare Personnel (HCP)

This measure was finalized in the FY 2022 IRF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR.42385 through 42396). Data submission for this measure began October 1, 2021.

Medicare Fee-For-Service Claims-Based Measures

The following are Medicare Fee-For-Service Claims-based measures. Because claims-based measures can be calculated using data that have already been submitted to the Medicare program for payment purposes, no additional information collection is required from IRFs.

IRF QRP Measure #15: Medicare Spending per Beneficiary (MSPB)–Post-Acute Care (PAC) IRF QRP (NQF #3561)

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52087 through 52095). Data for this measure began with CY 2016 claims data.

IRF QRP Measure #16: Discharge to Community–PAC IRF QRP (NQF #3479)

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52095 through 52103). Data for this measure began with CY 2016 claims data.

IRF QRP Measures #17: Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52103 through 52108). Data for this measure began with CY 2016 claims data.

IRF QRP Measure #18: Potentially Preventable Within Stay Readmission Measure

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52108 through 52111). Data for this measure began with CY 2016 claims data.

Measures Removed from the IRF QRP

1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678)

An application of this measure was finalized in the FY 2012 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2011 (76 FR 47873). The NQF-endorsed risk-adjusted version of the measure was adopted in the FY 2014 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2013 (78 FR 479011 through 47912). Data collection for this measure began on October 1, 2012. As finalized in the FY 2018 IRF PPS Final Rule, which was published in the Federal Register on August 3, 2017 (82 FR 36278 through 36283), this measure was replaced by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 IRF QRP.

2. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680)

This measure was finalized in the FY 2014 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2013 (78 FR 47910 through 47911). Data collection for this measure began on October 1, 2014. This measure was finalized for removal in the FY 2019 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2018 (83 FR 38559 through 38560).

3. NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716)

This measure was finalized in the FY 2015 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2014 (79 FR 45911 through 45913). Data collection for this measure began on January 1, 2015. The data for this measure are submitted via CDC/NHSN. This measure was finalized for removal in the FY 2019 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2018 (83 FR 38559). Data collection for this measure ended on October 1, 2018.

4. All Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Hospitals (NQF #2502)

This measure was finalized in the FY 2014 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2013 (78 FR 47906 through 47910). As finalized in the FY 2018 IRF PPS Final Rule, which was published in the Federal Register on August 3, 2017 (82 FR 36283 through 36284), this measure was removed beginning with the FY 2019 IRF QRP.

Updates


September 22, 2022

IRF QRP AIF Table for FY 2025

A table providing the data elements that will be required to meet the Annual Increase Factor (AIF) minimum data completion threshold for the Fiscal Year (FY) 2025 Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) is available in the Downloads section of this webpage.

September 1, 2022

IRF QRP Quality Measure Calculations and Reporting User’s Manual V4.0, Change Table, Risk Adjustment Appendix File, and HCC ICD-10 Crosswalks – Now Available

The Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User’s Manual Version 4.0 is now available. This document serves as an update to the specifications used to calculate quality measures that are included in the IRF QRP. Additionally, the IRF QRP Measure Calculations and Reporting User’s Manual Change Table Version 4.0 is now available. This document provides a summary of measure-related changes between Version 4.0 of the IRF QRP Measure Calculations and Reporting User’s Manual and Version 3.1.1 of the IRF QRP Measure Calculations and Reporting User’s Manual Addendum specified in change table format. Furthermore, the Risk Adjustment Appendix File for the IRF QRP Measure’s Calculations and Reporting User’s Manual Version 4.0, which contains risk-adjustment values used to calculate the risk-adjusted quality measures, and Crosswalks of Hierarchical Condition Categories (HCC) to International Classification of Diseases (ICD)-10 codes used in risk-adjustment models for the Change in Self-Care, Change in Mobility, Discharge Self-Care, and Discharge Mobility measures are available.

These files are effective October 1, 2022 and can be accessed in the Downloads section of this webpage.

November 9, 2021

IRF QRP AIF Table for FY 2024

A table providing the data elements that will be required to meet the Annual Increase Factor (AIF) minimum data completion threshold for the Fiscal Year (FY) 2024 Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) is available in the Downloads section.

August 16, 2021

IRF QRP Risk Adjustment Appendix File and ICD-10 HCC Crosswalks are now available.

An update to the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) Risk Adjustment Appendix File is now available. This document has been updated to reflect the risk adjustment coefficients for quality measure calculation to be used in conjunction with the IRF QRP Measure Calculations and Reporting User’s Manual (Version 3.1) and its corresponding addendum (Version 3.1.1). Additionally, the International Classification of Diseases, Tenth Edition (ICD-10) Hierarchical Condition Categories (HCC) Crosswalks for IRF Mobility (NQF #2634 and #2636) and Self-Care (NQF #2633 and #2635) functional outcome measures are available. These files can be accessed in the Downloads section of this webpage.

IRF Quality Reporting Program Archives

Page Last Modified:
10/13/2022 09:11 AM