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IRF Quality Reporting Spotlight & Announcements

What’s new with Inpatient Rehabilitation Facilities (IRFs) 

Updates 

August 05, 2019

August 15 and 16 IRF QRP Pre-Training Materials Are Now Available

Available on the IRF Quality Reporting Training webpage.

August 02, 2019

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 January 1 – March 31 (Q1) of calendar year (CY) 2019 are due with this submission deadline. 

All data must be submitted no later than 11:59 p.m. Pacific Standard Time on August 15, 2019. 

It is recommended that the applicable CMS CASPER 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 Annual Increase Factor (AIF) thresholds on a quarterly basis ahead of each submission deadline. 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.

July 31, 2019

Specifications for the quality measures and standardized patient assessment data elements for the IRF QRP finalized through the FY 2020 IRF PPS Final Rule are now posted. The specifications document provides detailed information on the new and updated measures: Transfer of Health Information to Provider–Post-Acute Care (PAC), Transfer of Health Information to Patient–Post-Acute Care (PAC), and Discharge to Community–Post-Acute Care (PAC) IRF QRP. The standardized patient assessment data elements and evidence of support for these data elements are also detailed in the specifications document. The specifications can be found in the Downloads section of the IMPACT Act Downloads and Videos webpage.

The new and modified sections of the IRF-PAI, along with a change table, effective October 1, 2020 for the measures and standardized patient assessment data elements finalized for the IRF QRP in the FY 2020 IRF PPS Final Rule can be found in the Downloads section of the IMPACT Act Downloads and Videos webpage.

The FY 2020 IRF PPS Final Rule is available at https://www.federalregister.gov/.

JULY 25, 2019

Important Reminder on Reconsideration Requests

Facilities that will be submitting reconsideration requests to CMS for the FY 2020 Annual Increase Factor (AIF) for the IRF Quality Reporting Program (QRP) are reminded that any documentation submitted for review that includes protected health information (PHI) will not be accepted, nor reviewed for reconsideration. Please redact any PHI prior to sending by completely removing all PHI from supporting documentation. If any of the documents included in a reconsideration request contain PHI, the entire request will be rejected and your reconsideration will not be reviewed. Facilities are encouraged to carefully review all supporting materials to ensure all PHI has been removed.

For more information visit the IRF Quality Reporting Reconsideration and Exception & Extension webpage

JULY 16, 2019

IRF Quality Reporting Program: Non-Compliance Letters

CMS is providing notifications to facilities that were determined to be out of compliance with the quality reporting requirements for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP), which will affect their FY 2020 Annual Increase Factor (AIF). Non-compliance notifications are in the process of being sent by the Medicare Administrative Contractors (MACs) and will be placed into facilities’ CASPER folders in QIES on July 16, 2019. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm PST, August 15, 2019. 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 11, 2019

May 9 and 10, 2019, IRF QRP Post-Training Materials Are Now Available

Available on the IRF Quality Reporting Training webpage.

July 03, 2019

REGISTRATION OPEN – IRF QRP Provider In-Person Training Event, August 15 and 16, 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 August 15 and 16, 2019, in Baltimore, MD. See the IRF Quality Reporting Training webpage for details.

June 26, 2019

NEW TRAINING EVENT — Updated Section GG Web-based Training Course

The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course on how to properly code of Section GG. This 45-minute course is intended for providers in the following care settings: Skilled Nursing Facilities (SNFs), Long-Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), and Home Health Agencies (HHAs); and is designed to be used on demand anywhere you can access a browser. The course is divided into the following four lessons and includes interactive exercises that allow you to test your knowledge in real life scenarios:

• Lesson 1: Importance of Section GG for Post-Acute Care

• Lesson 2: Section GG Assessment and Coding Principles

• Lesson 3: Coding GG0130.Self-Care Items

• Lesson 4: Coding GG0170.Mobility Items

Click here to access the training.

If you have technical questions or feedback regarding the training, please email the PAC Training mailbox. Content-related questions should be submitted to the Quality Reporting Program Help Desk for your care setting.

June 19, 2019

Dear Inpatient Rehabilitation Facility (IRF) Provider: 

The Quality Improvement and Evaluation System (QIES), which providers and vendors use to submit assessment data, is being upgraded to make the system more reliable, scalable, secure, and accessible. The enhancements will occur in phases (by provider type) and began with Long- Term Care Hospitals (LTCHs) in March 2019. The enhanced system is referred to as the Internet Quality Improvement and Evaluation System (iQIES) and is aimed at reducing provider burden and enhancing CMS’s ability to serve our customers.

The initial rollout of iQIES will not change how providers or vendors submit data. However, iQIES will require a new user management system because virtual private network (VPN) and CMSNet are no longer needed to access this system. All users will have to create an account and establish credentials in the HCQIS Access Roles and Profile system (HARP). HARP is a secure identity management portal that the Centers for Medicare & Medicaid Services (CMS) provides. 

Through HARP, the level of access for iQIES will be similar to the roles that exist in QIES but with the addition of a Provider Security Official (PSO). The individual designated as the PSO will be responsible for approving or rejecting iQIES user access requests for their respective organizations, including vendors. 

For your organization to receive access to iQIES, your organization must complete the steps below by June 30, 2019: 

  1. Identify an individual who will be the Provider Security Official (PSO).

 

  1. Register the PSO in the Healthcare Quality Information System (HCQIS) Access Roles and Profile (HARP) system at: https://harp.qualitynet.org/register/profile-info.

 

  1. For assistance with HARP onboarding, users can call the QTSO Helpdesk at (800) 339-9313 or e-mail help@qtso.com. If you have any questions related to iQIES, please send them to iQIES_Broadcast@cms.hhs.gov

***Although onboarding for IRFs will begin in June, iQIES assessment submission functionality will not be available until October 1, 2019. Although this functionality will not be available immediately, we encourage IRF security officials to request access to iQIES as soon as onboarding for your organization has begun. Upon receiving access, security officials will have access to ‘My Profile’ and ‘Help’ in iQIES.

To comply with federal security mandates, CMS is initiating new security requirements for access control to CMS Quality Systems through Remote Identify Proofing (RIDP) via the Healthcare Quality Information System (HCQIS) Access, Roles and Profile Management system. Users will create accounts in HCQIS Access Roles and Profile Management (HARP) to gain access to the iQIES system. CMS has prepared a fact sheet with more information about this process. To view the fact sheet, visit: https://qtso.cms.gov/news-and-updates/remote-identify-proofing-requirements-internet-quality-improvement-evaluation-0 

Frequently Asked Questions (FAQs) related to HARP can be accessed using the following link: https://harp.qualitynet.org/login/help

June 12, 2019

The 2019 Data Collection Periods for IRF Compare are now available in the downloads section of the IRF Quality Public Reporting webpage.

June 10, 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 September 2019 refresh.

For more information:

June 07, 2019

The IRF QRP Table for Reporting Assessment-Based Measures for the FY2021 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 2021 IRF QRP determination. 

June 07, 2019

Video Tutorials Available to Assist with Coding Specific Section GG Items

Accessible from the following webpages:

Home Health QRP Training webpage

Inpatient Rehabilitation Facility QRP Training webpage

Long-Term Care Hospital QRP Training webpage

Skilled Nursing Facility QRP webpage

June 05, 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.

June 04, 2019

Enhanced Assessment Submission & Processing System/User Tool for Inpatient Rehabilitation Facilities for October 1, 2019

In March 2019, the Centers for Medicare & Medicaid Services (CMS) began a series of Quality Improvement and Evaluation System (QIES) enhancements, starting with the upgrade of the Long-Term Care Hospital (LTCH) Assessment Submission and Processing (ASAP) system. The enhancements to the system for LTCHs is the first of multiple releases, resulting in what is now called the Internet Quality Improvement and Evaluation System (iQIES). These updates aim to reduce provider burden and enhance CMS’s ability to serve our customers.

The release scheduled for October 1, 2019, will include the enhanced Inpatient Rehabilitation Facility (IRF) patient assessment upload functionality as well as an optional patient assessment user tool that will allow for direct assessment submission to iQIES. This tool will replace jIRVEN and may be used by IRFs as an option to vendor software currently being used to submit assessments. Because iQIES is an Internet facing, cloud based system, it will be more reliable, intuitive, secure, and accessible.

What to Expect/Future Communications

For additional information about the release of iQIES for IRFs, the following communications will be made available in the coming weeks and in subsequent months:

  • iQIES Provider Security Official Request Letter – Instructions on how your organization can assign a “Provider Security Official” and begin the account creation process. We expect to start onboarding IRF Security officials in June 2019.*
  • iQIES Training Video Announcement – Resources for how to navigate the iQIES system and how to utilize the improved functionality.
  • iQIES XML Upload/Assessment Tool Release Announcement- Announcement of October 1st Go-Live date for IRFs
  • iQIES FAQs – Frequently asked questions that will be updated periodically based on end-user feedback to improve the overall experience.

*Although onboarding for IRFs will commence in June, iQIES assessment submission functionality will not be available until October 1, 2019.

Please contact our service desk at: help@qtso.com or by phone: 800-339-9313 with any questions.

May 31, 2019

Update of the Discharge to Community Measure for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP)

Beginning fall 2019, CMS will publicly display on IRF Compare the updated measure results for the Discharge to Community Measure adopted for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP), using updated methodology related to the assignment of categorical ratings to each provider based on their performance on this measure (better than, same as, or worse than the national average). For more information, please visit the IRF Quality Public Reporting webpage.

May 30, 2019

Publication of Potentially Preventable Readmission Measures for the Post-Acute Care Quality Reporting Programs (QRPs)

Beginning fall 2019, CMS will publicly display measure results on the Inpatient Rehabilitation Facility Compare website for the following two measures: the Potentially Preventable 30-Day Post-Discharge Readmissions and Potentially Preventable Within-Stay Readmissions measures adopted for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP). For more information, please visit the IRF Quality Public Reporting webpage.

May 09, 2019

FY 2020 IRF PPS Proposed Rule Correction

Subsequent to the publication of the FY 2020 IRF PPS proposed rule (84 FR 17244 through 17335), we discovered a typographical error in the calculation of the estimated burden for the IRF QRP.  We are notifying readers of these edits via the Post-Acute Care Listserv and an announcement on the Inpatient Rehabilitation Facility Quality Reporting Program Spotlight and Announcements webpage.  

On page 17329 of the proposed rule it states, “Specifically, we believe that there will be an addition of 7.4 minutes on admission, and 11.1 minutes on discharge, for a total of 8.9 minutes of additional clinical staff time to report data per patient stay.” This sentence should have stated, “Specifically, we believe that there will be an addition of 7.8 minutes on admission, and 11.1 minutes on discharge, for a total of 18.9 minutes of additional clinical staff time to report data per patient stay.”

 Please note, the final values and the overall burden proposed in the rule is correct despite these minor typographical errors.  We intend to correct the figures in the final rule.

May 03, 2019

May 9 and 10 IRF QRP Pre-Training Materials Are Now Available

Available on the IRF Quality Reporting Training webpage.

May 02, 2019

The data collection time frames and final submission deadlines documents for the FY 2020 IRF QRP and FY 2021 IRF QRP have been updated to reflect the Quarter 3 data submission deadline extension (February 15, 2019 to February 21, 2019). The updated documents are available in the Downloads section of the IRF QRP Data Submission Deadlines webpage.

April 30, 2019

Policy Change for Assessment Submission Timeframe

The current CMS policy for submission of patient assessment records allows providers to submit records for up to 36 months from the assessment target date.  Effective October 1, 2019, the CMS policy for patient assessment submission will be changed to 24 months from the assessment target date.  The policy change applies to new, modified, and inactivated records.

April 30, 2019

Updated IRF-PAI Manual Version 3.0

The IRF-PAI Manual version 3.0 and accompanying change table have been added to the IRF-PAI and IRF QRP Manual webpage. This manual contains information regarding data collection on the IRF-PAI version 3.0, effective October 1, 2019. Please note that the IRF-PAI Manual replaces previous versions of the IRF-PAI Training Manual.

April 25, 2019

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 1 – December 31 (Q4) 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 May 15, 2019. 

It is recommended that the applicable CMS CASPER 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 deadline. 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.

April 18, 2019

Proposed specifications for the quality measures and standardized patient assessment data elements proposed for the IRF QRP through the FY 2020 IRF PPS Proposed Rule are now posted. The specifications document provides detailed information on the proposed new and updated measures: Transfer of Health Information to Provider–Post-Acute Care (PAC), Transfer of Health Information to Patient–Post-Acute Care (PAC), and Discharge to Community–Post-Acute Care (PAC) IRF QRP. The standardized patient assessment data elements and evidence of support for these data elements are also detailed in the specifications document. The specifications can be found in the Downloads section of the IMPACT Act Downloads and Videos web page.

The new and modified sections of the IRF-PAI, along with a change table, effective October 1, 2020 for the measures and standardized patient assessment data elements proposed for the IRF QRP in the FY 2020 IRF PPS Proposed Rule can be found in the Downloads section of the IMPACT Act Downloads and Videos web page.

The FY 2020 IRF PPS Proposed Rule is available at https://www.federalregister.gov/.

April 5, 2019

IRF QRP Review and Correct Reports Now Available

The enhanced Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) review and correct reports are now available on demand in the Certification and Survey Provider Enhanced Reporting (CASPER) application. In addition to enhanced sorting functionality, this report now includes patient level data and automated CSV file creation functionality that contains patient level results. Providers can access these reports by selecting the CASPER Reporting link on the “Welcome to the CMS QIES Systems for Providers” webpage.

NOTE: You must log into the CMS Network using your CMSNet user ID and password in order to access the “Welcome to the CMS QIES Systems for Providers” webpage.

In addition to the sorting enhancements and inclusion of patient level data, these reports:

  • Contain quality measure information at the facility level
  • Allow providers to obtain aggregate performance for the past four quarters (when data are available)
  • Include data submitted prior to the applicable quarterly data submission deadlines
  • Display whether the data correction period for a given CY quarter is “open” or “closed”.

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.

 

 

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