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 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 47080). Data collection for this measure began on October 1, 2016.

IRF 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 (NQF #2631)

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 47080). Data collection for this measure began on October 1, 2016.

IRF 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 (47080). Data collection for this measure began on October 1, 2016.

IRF 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 47080). Data collection for this measure began on October 1, 2016.

IRF 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 47080). Data collection for this measure began on October 1, 2016.

IRF 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 47080). Data collection for this measure began on October 1, 2016.

IRF 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 52080). Data collection for this measure began on October 1, 2018.

IRF 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 36269). Data collection for this measure began on October 1. This measure replaced Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678).

IRF 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 39098). Data collection for this measure is to be determined.

IRF 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 39098). Data collection for this measure is to be determined.

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 Measure #1: 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 68500). Data submission for this measure began on October 1, 2012.

IRF Measure #2: 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 47904). Data submission for this measure began on October 1, 2014.

IRF Measure #3: 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 45908). Data submission for this measure began on January 1, 2015.

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 Measure #1: Medicare Spending per Beneficiary (MSPB)–Post-Acute Care (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 52080). Data for this measure began with CY 2016 claims data.

IRF Measure #2: 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 52080).  Data for this measure began with CY 2016 claims data.

IRF Measures #3: 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 52080). Data for this measure began with CY 2016 claims data.

IRF Measure #4: 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 52080). 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 47902). 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 36269), 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 47902). 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 3857638554).

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 45908). 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 38554). 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 47902). This is a claims-based measure, and no additional data need to be submitted by the IRF. As finalized in the FY 2018 IRF PPS Final Rule, which was published in the Federal Register on August 3, 2017 (82 FR 36269), this measure was removed beginning with the FY 2019 IRF QRP.

Updates

November 09, 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 ICD-10 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:
12/01/2021 08:00 PM