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IRF Quality Reporting Spotlight & Announcements

What’s new with Inpatient Rehabilitation Facilities (IRFs) 

Updates

March 20, 2019

REGISTRATION OPEN – IRF QRP Provider In-Person Training Event, May 9 and 10, 2019

The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) in-person 'Train the Trainer' event for providers on May 9 and 10, 2019, in Kansas City, MO. See the IRF Quality Reporting Training webpage for details

March 6, 2019

IRF Compare Quarterly Refresh

The Inpatient Rehabilitation Facility (IRF) Compare website has been updated.

For more information visit the CMS IRF QRP Public Reporting website.

March 4, 2019 IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores on quality measures, which will be published on IRF Compare during the June 2019 refresh.

For more information:

February 20, 2019 

Post-Acute Care Quality Reporting Program Quarter 3 Data Submission Deadline Extension 

CMS is aware of the issue with CMSNet that impacted post-acute care (PAC) providers’ ability to submit assessment data for the quality reporting programs (QRP) to the QIES-ASAP system on the Quarter 3 data submission deadline of February 15, 2019. We have extended the data submission deadline, and we will be accepting QRP assessment data submissions through, Thursday, February 21, 2019. Providers can also apply for an extension following the instructions listed on the PAC QRP Reconsiderations and Exception & Extension webpages if they are unable to meet this extension deadline. 

January 25, 2019

Updated PRA Disclosure Statement for IRF-PAI Version 3.0

The IRF-PAI Version 3.0 has been updated with the most recent PRA Disclosure Statement. Please find the updated document in the downloads section of the IRF-PAI and IRF QRP Manual webpage.

January 25, 2019

Section GG Decision Tree Training Document Now Available

A decision tree training document to help with coding Section GG self-care and mobility data elements is now available. This document provides an overview of the 6 codes and coding instructions for admission/discharge. Please see the IRF Quality Reporting Training webpage for details.

December 12, 2018

IRF Compare Quarterly Refresh

The Inpatient Rehabilitation Facility (IRF) Compare website has been updated.

For more information visit the CMS IRF QRP Public Reporting website 

December 06, 2018

A table providing the data collection time frames and final submission deadlines for the FY 2021 IRF QRP is available in the Downloads section of the IRF QRP Data Submission Deadlines webpage. 

December 06, 2018

Disaster Information Now Available on the Reconsiderations and Exceptions & Extensions Page

For all disaster related information moving forward, please visit the Reconsiderations and Exceptions & Extensions web page for your Quality Reporting Program. Memos will be posted in the downloads section of this page with additional information for each specific disaster impacting the Quality Reporting Programs.

December 03, 2018

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores on quality measures, which will be published on IRF Compare during the March 2019 refresh.

For more information:

November 27, 2018

Post-Training Materials Available – September 2018 IRF and LTCH Section N: Medications Webinar

Available under the Downloads section of the Inpatient Rehabilitation Facility (IRF) Quality Reporting Training and Long-Term Care Hospital (LTCH) Quality Reporting Training webpages.

November 06, 2018

Please note that while the IRF QRP no longer requires IRFs to submit data for the following measures, reporting on this data is required for certain IRFs based on state and local mandates:

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

Please check your state and local mandates to ensure you are in compliance with their reporting requirements.

November 02, 2018

IRF QRP APU FY 2019: Successful Facilities

As stated in the FY 2016 IRF PPS Final Rule, CMS has published a list of IRFs who successfully met the reporting requirements after all reconsideration requests have been processed. View the list on the IRF Quality Reporting Data Submission Deadlines webpage.

October 29, 2018

For all QRP web pages that reference  qtso.com please update to new web address to qtso.cms.gov

October 24, 2018

The submission deadline for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) is approaching. IRF-PAI assessment data and data submitted via the Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for April 1 – June 30 (Q2) of calendar year (CY) 2018 are due with this submission deadline. 

All data must be submitted no later than 11:59 p.m. Pacific Standard Time on November 15, 2018. 

It is recommended that the applicable CMS CASPER validation reports and NHSN analysis reports are run prior to each quarterly reporting deadline to ensure that all required data were submitted. We encourage you to verify all facility information prior to submission, including CCN and facility name. 

View the list of measures required for this deadline in the Downloads section on the IRF Quality Reporting Data Submission Deadlines webpage. 

For additional information, visit:

CORMAC sends informational messages to IRFs that are not meeting APU thresholds on a quarterly basis ahead of each submission deadlines. If you need to add or change the email addresses to which these messages are sent, please email QRPHelp@cormac-corp.com and be sure to include your facility name and CMS Certification Number (CCN) along with any requested email updates.

October 19, 2018

IRF Quality Measure Reports- Measures Added

The Confidential Feedback Reports, also referred to as the Facility-Level and Patient-Level Quality Measure (QM) reports, for Inpatient Rehabilitation Facilities (IRFs) have been updated to include additional quality measures. These on-demand, user-requested reports, are available via the Certification and Survey provider Enhanced Reports (CASPER) Reporting System. These reports can be used to provide feedback to help providers identify data errors and improve quality of care. For more information, view the “IRF QM Report - Measures Added - October 2018” PDF on the IRF Quality Reporting Measures Information webpage.

October 11, 2018

Post-Training Materials Available – September 2018 IRF and LTCH Section M Webinar

Post-training materials (includes answers to knowledge checks) from the Inpatient Rehabilitation Facility (IRF) and Long-Term Care Hospital (LTCH) Section M: Skin Conditions (Pressure Ulcer/Injury) Webinar held September 4, 2018, are available under the Downloads section of the Inpatient Rehabilitation Facility (IRF) Quality Reporting Training and Long-Term Care Hospital (LTCH) Quality Reporting Training respect webpages.

October 11, 2018

Hurricane Florence - Disaster Exceptions/Exemptions for Medicare Certified Providers Affected by Severe Storms and Flooding

The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs located in areas affected by Hurricane Florence. These healthcare providers and suppliers will be granted exceptions without having to submit a request if they are located in one of the counties listed in the memo posted on October 11, 2018, all of which have been designated by the Federal Emergency Management Agency (FEMA) as a major disaster county. Please check this site for the most up to date list of affected counties.

For IRFs outside the FEMA-designated counties affected by Hurricane Florence, please follow the directions related to requesting an exemption or extension, as listed on the IRF Quality Reporting Reconsideration and Exception & Extension website.

September 27, 2018

IRF Compare Quarterly Refresh – September 2018

The September 2018 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including new quality measure results based on data submitted to CMS between Q4 2016 – Q3 2017, is now available. We invite you to visit IRF Compare to view the data.

In addition to IRF QRP measures that are currently displayed on IRF Compare, the following four new quality measures will be displayed:

Assessment-based measures:

  1. Application of Percent of Long-Term Care Hospital (LTCH) Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
  2. Application of Percent of Residents Experiencing One or More Falls with Major Injury (NQF #0674)
  3. Claims-based measures:
  4. Medicare Spending Per Beneficiary-PAC IRF QRP
  5. Discharge to Community-PAC IRF QRPCMS has decided not to publish two additional quality measures, Potentially Preventable 30-Day Post-Discharge Readmissions and Potentially Preventable Within-Stay Readmissions, at this time.   Additional time would allow for more testing to determine if there are modifications that may be needed both to the measures and to the method for displaying the measures. This additional testing will ensure that the future publicly reported measures are thoroughly evaluated so that Compare users can depend upon an accurate picture of provider quality.   While we conduct this additional testing, CMS will not post reportable data for these measures, including each IRF’s performance, as well as the national rates. Please visit the IRF Compare Website to view the new and updated quality data.
  6. For more information visit the CMS IRF QRP Public Reporting website.

September 24, 2018

Updated IRF QRP FAQ Document

An updated version of the IRF QRP FAQ document is located in the Downloads section of the IRF Quality Reporting FAQs page. This document has been updated to reflect policies finalized in the FY 2019 IRF PPS final rule and other useful frequently asked questions and resources available to providers.

September 14, 2018

The following documents have been updated to reflect the removal of the National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure (NQF #1716), and the Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay) (NQF #0680) measure from the IRF QRP as finalized in the FY 2019 IRF PPS final rule effective October 1, 2018:

  1. Data Collection and Submission Deadlines for the FY 2020 IRF QRP document is available in the Downloads section of the IRF Quality Reporting Data Submission Deadlines webpage.
  2. IRF QRP Table for Reporting Assessment-Based Measures for the FY 2020 IRF QRP document is available in the Downloads section of the IRF Quality Reporting Measures Information webpage.

September 14, 2018

A Quick Reference Guide for the IRF QRP for FY2020 is now available on the IRF Quality Reporting Data Submission Deadlines page.  The guide includes frequently asked questions, information on QRP help desks, and helpful links to additional resources for the IRF QRP.

September 12, 2018 

IRF and LTCH Section N Follow-Up Webinar Rescheduled for Monday, September 17, from 2:00 to 3:30 p.m.

The Inpatient Rehabilitation Facility (IRF) and Long-Term Care Hospital (LTCH) Section N Follow-Up Webinar originally held on Wednesday, August 29, 2018, from 2:00 to 3:30 p.m. has been rescheduled due to technical difficulties experienced during the webinar. See the LTCH Quality Reporting Training  and IRF Quality Reporting Training web pages for details. 

September 07, 2018

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available. Providers have until October 8, 2018 to review their performance data on quality measures based on Quarter 1 -2017 to Quarter 4 - 2017 data, prior to the December 2018 IRF Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data scores displayed are inaccurate.

For more information:

August 27, 2018

Pre-Training Materials Now Available for the Upcoming IRF and LTCH Webinars (August 29 and September 4, 2018) Related to Changes Associated with Coding Sections N and M of the LTCH CARE Data Set and the IRF-PAI

The training materials for the upcoming Section N webinar, scheduled for Wednesday, August 29, 2018, from 2:00 to 3:30 p.m. EDT and Section M webinar scheduled for Tuesday, September 4, 2018, from 2:00 to 3:30 p.m. EDT are now available under the Downloads section of the Inpatient Rehabilitation Facility (IRF) Quality Reporting Training and Long-Term Care Hospital (LTCH) Quality Reporting Training webpages. 

August 21, 2018

IRF Quality Reporting Program Measures Calculations and Reporting User’s Manual V3.0

The IRF Quality Reporting Program Measures Calculations and Reporting User’s Manual V3.0 has been added to the Downloads section of the IRF Quality Reporting Measures Information page. This version of the IRF-PAI-based User’s Manual is effective on October 1, 2018 and provides detailed information for each quality measure, including quality measure definitions, inclusion and exclusion criteria, and measure calculation specifications. A Change Table has been added to highlight the changes from IRF Quality Reporting Program Measures Calculations and Reporting User’s Manual V2.0 to V3.0. Additionally, we have included a Risk Adjustment Appendix File for the IRF Quality Reporting Program Measures Calculations and Reporting User’s Manual V3.0, which contains the risk-adjustment values used to calculate the risk-adjusted quality measures. Please note: As listed in the Risk Adjustment Appendix File, under the “Schedule” tab, the 12 month coefficient and intercept values will be applied to the records of patients discharged between 10/1/2016 and 9/30/19 for the four IRF Functional Outcome Measures (Risk-Adjustment Update ID #1 for the Change in Self-Care/Mobility Measures; Update ID #2 for the Discharge Self-Care/Mobility Measures). These values will replace the temporary 9 month values (Risk-Adjustment Update ID #1) used to calculate the Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635) and Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636) measures displayed on providers’ Review and Correct reports. The Change Table and Risk Adjustment Appendix File are also available for download on the IRF Quality Reporting Measures Information webpage.

 

August 10, 2018

May 9 and 10 IRF QRP Provider Training Q+A is Available  

The question and answer (Q+A) for the May 9 and 10, 2018 Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Training is now available. See the IRF Quality Reporting Training webpage for details. 

August 07, 2018

A zip file containing an errata document and revised pages for IRF-PAI Training Manual V2.0 (Section 4 – Quality Indicators) has been posted and is available in the downloads section of the IRF-PAI & IRF QRP Manual webpage.

July 31, 2018

IRF-PAI V3.0 and Change table

An updated version of the IRF-PAI Version 3.0 (as finalized in the FY 2019 IRF PPS Final Rule), along with a change table describing updates, has been added to the Downloads section of the IRF-PAI and IRF QRP Manual webpage. The IRF-PAI V3.0 is effective October 1, 2019.

July 23, 2018

REGISTRATION OPEN – Upcoming IRF and LTCH QRP Webinars (August 29 and September 4, 2018) Related to Changes Associated with Coding Sections N and M of the LTCH CARE Data Set and the IRF-PAI

The Centers for Medicare & Medicaid Services (CMS) will be hosting two webinars for providers at Long-Term Care Hospitals and Inpatient Rehabilitation Facilities to present information about proper coding of Section M Skin Conditions (Pressure Ulcer/Injury) and Section N of the Continuity Assessment Record and Evaluation (CARE) Data Set Version 4.00 and the Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) Version 2.00. Updated reporting requirements for Sections M and N became effective on July 1, 2018, for LTCH providers and will become effective on October 1, 2018, for IRF providers. See the LTCH Quality Reporting Training  and IRF Quality Reporting Training web pages for details. 

July 06, 2018

IRF Quality Reporting Program: Non-Compliance Letters

CMS is providing notifications to facilities that were determined to be out of compliance with Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) requirements for CY 2017, which will affect their FY 2019 Annual Increase Factor (AIF). Non-compliance notifications are in the process of being mailed by the Medicare Administrative Contractors (MACs) and will be placed into facilities’ CASPER folders in QIES on July 9, 2018. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59pm PST, August 7, 2018. If you receive a notice of non-compliance and would like to request a reconsideration, see the instructions in your notification letter and on the IRF Quality Reporting Reconsideration and Exception & Extension webpage.

July 03, 2018

The Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN) require providers to complete a new Agreement to Participate and Consent form for the Patient Safety and the Healthcare Personnel Safety Components by Monday, July 9, 2018.   IRFs participating in the Centers for Medicare & Medicaid Services (CMS) Quality Reporting Program (QRP) must accept the updated NHSN Agreement to Participate and Consent forms to avoid interruptions in your healthcare facility’s access to NHSN, including access for purposes of submitting data to meet IRF QRP reporting requirements.  

These forms are available for review and completion in the NHSN application.  If you have any questions about the consent process, please email the NHSN help desk at NHSN@cdc.gov

June 26, 2018

Data Collection & Final Submissions Deadlines table posted

A table providing the data collection time frames and final submission deadlines for the FY 2020 IRF QRP has been posted in the Downloads section of the IRF QRP Data Submission Deadlines webpage. 

June 22, 2018

May 2018 IRF QRP Post-Training Materials Are Now Available

Post-training materials from the May 2018 Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Provider Training held in Baltimore, MD, on May 9 and 10, 2018, are now available in the Downloads section of the IRF Quality Reporting Training webpage.

June 07, 2018

The IRF QRP Table for Reporting Assessment-Based Measures for the FY 2020 IRF QRP APU is now available for download on the IRF Quality Reporting Measures Information webpage. This table indicates the IRF-PAI data elements that are used in determining the APU minimum submission threshold for the FY 2020 IRF QRP determination. Please note this replaces the IRF QRP Technical Specifications for Reporting Assessment-Based Measures document.

June 06, 2018

IRF Compare Quarterly Refresh Available

The June 2018 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q3 2016 – Q2 2017, is now available. We invite you to visit IRF Compare to view the data. 

For more information, view the CMS IRF Quality Public Reporting webpage.

June 01, 2018

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 4 -2016 to Quarter 3 - 2017 data, prior to the September 2018 IRF Compare refresh, during which this data will be publicly displayed.

Providers have until July 1, 2018 to review their performance data.

Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

The updates include two additional assessment-based measures and four new claims-based measures.

New IRF Assessment-based measures:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) (NQF #0674)
  • 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)

New IRF Claims-based measures:

  • Medicare Spending per Beneficiary (MSPB)–PAC IRF QRP
  • Discharge to Community–PAC IRF QRP
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP
  • Potentially Preventable Within Stay Readmission Measure

The update also includes the removal of the All-Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Facilities measure.

For more information:

IRF Quality Public Reporting webpage, IRF Compare, and Preview Report Access Instructions

May 17, 2018

Now posted: Errata and IRF-PAI Training Manual Version 2.0 - Revised Section 4 (Quality Indicators)

An errata has been posted, along with a file containing the IRF-PAI Training Manual Section 4 (Quality Indicators) with revised Sections GG and M, has been posted in the Downloads section of the IRF-PAI and IRF QRP Manual webpage.

May 08, 2018

Updated Section 4 (Quality Indicators) of IRF-PAI Training Manual Version 2.0

An updated version of Section 4, the Quality Indicators sections, of the IRF-PAI Training Manual Version 2.0, along with a change table describing updates, has been added to the Downloads section of the IRF-PAI and IRF QRP Manual  webpage. These sections contain information regarding data collection for the quality measures on the IRF-PAI version 2.0, effective October 1, 2018.

May 04, 2018

Training Materials Available for IRF QRP Provider In-Person Training Event, May 9-10, 2018

The training materials for the upcoming Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Provider Training in Baltimore, MD, on Wednesday, May 9, and Thursday, May 10, are now available under the Downloads section of the IRF Quality Reporting Training webpage. The training will start at 8:30 a.m. EDT and end at 5:00 p.m. EDT on May 9, and start at 8:30 a.m. EDT and end at 3:45 p.m. EDT on May 10. Click here to register for this event.

April 27, 2018 

Proposed IRF-PAI V3.0 – Effective October 1, 2019 (FY 2020)

The IRF-PAI Version 3.0 – Effective October 1, 2019 (FY 2020), as proposed in the FY 2019 IRF PPS proposed rule, and a table listing changes from the previous version can be found in the Downloads section of the IRF-PAI and IRF QRP Manual webpage.

April 20, 2018

The submission deadline for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) is approaching. IRF-PAI assessment data and data submitted via the Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for October-December (Q4) of calendar year (CY) 2017 are due with this submission deadline. Influenza Vaccination among Healthcare Personnel (NQF #0431) for October 1, 2017 – March 31, 2018 is also due with this submission deadline via NHSN.

All data must be submitted no later than 11:59 p.m. Pacific Standard Time on May 15, 2018.

It is recommended that the applicable CMS CASPER validation reports and NHSN analysis reports are run prior to each quarterly reporting deadline to ensure that all required data were submitted. We encourage you to verify all facility information prior to submission, including CCN and facility name.

View the list of measures required for this deadline in the Downloads section on the IRF Quality Reporting Data Submission Deadlines webpage.

For providers affected by hurricanes Harvey, Irma, Maria, or Nate, or the California wildfires: Information on the exceptions can be found on the IRF Quality Reporting Reconsideration and Exception & Extension webpage.

For additional information, visit:

March 23, 2018

REGISTRATION OPEN – IRF QRP Provider In-Person Training Event, May 9-10, 2018

The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) in-person 'Train the Trainer' event for providers on May 9 and 10, 2018, in Baltimore, MD. See the IRF Quality Reporting Training webpage for details.

March 07, 2018 

IRF Provider Preview Reports- Now Available

Inpatient Rehabilitation Facility (IRF) Provider Preview Reports are now available.  Providers have the opportunity to review their performance data on quality measures based on Quarter 3 -2016 to Quarter 2 - 2017 data, prior to the June 2018 IRF Compare refresh, during which this data will be publicly displayed.

Providers have until April 5, 2018 to review their performance data.

Corrections to the underlying data will not be permitted during this time. However, providers can request a CMS review during the preview period if they believe their data is inaccurate. 

For more information:

March 07, 2018

SAVE THE DATE for the May 9-10 IRF QRP Provider Training

The Centers for Medicare & Medicaid Services (CMS) will be hosting a 2-day Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) in-person ‘Train the Trainer’ event for providers on May 9 and 10, 2018, in Baltimore, MD. See the IRF Quality Reporting Training webpage for details.

March 02, 2018

The March 2018 quarterly Inpatient Rehabilitation Facility (IRF) Compare refresh, including quality measure results based on data submitted to CMS between Q2 2016 – Q1 2017, is now available. Visit IRF Compare to view the data. 

For more information, view the IRF Quality Public Reporting webpage.

December 20, 2017

NEW TRAINING EVENT — Section GG Web-based Training Module Now Available

The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training module to address questions submitted by providers during trainings between November 2015 and August 2016 related to Section GG across the Skilled Nursing Facility (SNF), Long-Term Care Hospital (LTCH), Inpatient Rehabilitation Facility (IRF), and Home Health (HH) care settings. Visit the IRF Quality Reporting Training webpage for more information.

IRF Quality Reporting Spotlight Archives

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