Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Spotlights & Announcements

Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Spotlights & Announcements

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Updates

March 27, 2024

IRF PPS for FY 2025; and Updates to the IRF QRP (CMS-1804-P) 

On March 27, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1804-P) that provides proposals for the fiscal year (FY) 2025 Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP). This proposed rule includes four new assessment items in the Social Determinants of Health (SDOH) category: (1) Living Situation, (2) Food, and (3) Utilities. CMS is also proposing to modify the Transportation item and remove the Admission class item from the IRF-Patient Assessment Instrument (PAI). Finally, CMS is seeking feedback with two Requests for Information (RFIs) on quality measure concepts under consideration for future IRF QRP years and a star rating system for the IRF QRP.

 The proposed rule went on display at the Federal Register and will be available at: https://www.federalregister.gov/public-inspection

March 20, 2024

CMS IRF-PAI Quarterly Q&As, March 2024, Consolidated June 2020 to March 2024

The Centers for Medicare & Medicaid Services (CMS) is publishing the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Quarterly Q&As, in March of 2024. The document contains the consolidated Q&As from June 2020 to March 2024 so that all IRF providers have the benefit of the clarifications to existing guidance. Through inquiries to the IRF Post-Acute Care (PAC) Quality Reporting Program (QRP) Help Desk, CMS identifies the opportunity to clarify or refine guidance. While no new Q&As were added to the consolidated document for this release, CMS has archived some Q&As either because the guidance has been added to the IRF-PAI 4.2 Manual, or the Q&As have been retired.

The Quarterly Q&A document can be accessed via the Downloads section of the IRF-PAI and IRF-PAI Manual webpage.

March 15, 2024

IRF Provider Preview Reports – Now Available

The Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the June 2024 refresh.

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

February 9, 2024

Reminder of Upcoming Data Submission Deadline

The submission deadline for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) is approaching. IRF Patient Assessment Instrument (IRF-PAI) assessment data and data submitted via the Center for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for July 1 – September 30 (Q3) of calendar year (CY) 2023 are due with this submission deadline. 

All data must be submitted no later than 11:59 p.m. on February 15, 2024.

It is recommended that the applicable Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) 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 CMS Certification Number (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 submission information, visit:

Swingtech sends informational messages to IRFs that are not meeting Annual Increase Factor (AIF) threshold 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@swingtech.com and be sure to include your facility name and CCN along with any requested email updates.

February 1, 2024

CMS IRF-PAI Manual Version 4.2 

The Centers for Medicare & Medicaid Services (CMS) is publishing the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Manual, Version 4.2, effective October 1, 2024. A Change Table outlining the revisions to the CMS IRF-PAI Manual Version 4.2 is also published.

The Manual and Change Table can be accessed via the Downloads section of the IRF-PAI and IRF QRP Manual webpage. 

January 19, 2024

NOW AVAILABLE: CMS Frequently Asked Questions (FAQ) Document and Methodology Report for the Post-Acute Care Health Equity Confidential Feedback Reports 

In October 2023, the Centers for Medicare & Medicaid Services (CMS) released two Health Equity Confidential Feedback Reports to post-acute care (PAC) providers: the Discharge to Community (DTC) Health Equity Confidential Feedback Report and the Medicare Spending Per Beneficiary (MSPB) Health Equity Confidential Feedback Report.

To answer frequently asked questions and to provide methodological information about these reports, CMS released the Frequently Asked Questions (FAQ) Document and the Methodology Report. The materials can be access through these links: 

December 20, 2023

Care Compare December Refresh of IRF QRP Data – Now Available

The December 2023 Refresh of the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).

For more information, please visit the IRF QRP Public Reporting website.

December 15, 2023

IRF Provider Preview Reports – Now Available

The Inpatient Rehabilitation Facility (IRF) Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on Care Compare and Provider Data Catalog (PDC) during the March 2024 refresh.

For more information, please visit the IRF QRP Public Reporting website.

December 15, 2023

NOW AVAILABLE: CMS Health Equity Confidential Feedback Reports Live Q&A Materials

On November 16, 2023, the Centers for Medicare & Medicaid Services (CMS) hosted a live Q&A session about the CMS Health Equity Confidential Feedback Reports for post-acute care (PAC) providers in the Home Health (HH), Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) settings, which were released in October 2023. The PAC Health Equity Confidential Feedback Reports stratified the Discharge to Community and Medicare Spending Per Beneficiary measures by dual-enrollment status and race/ethnicity. 

The live Q&A session gave participants an opportunity to ask CMS subject matter experts about the report’s methodologies and interpretations. 

The webinar’s recording, slides, and transcript can be found at the Training webpage for HHIRFLTCH, and SNF.

December 13, 2023

NEW RESOURCE AVAILABLE: Confusion Assessment Method (CAM©) Video Tutorial

The Centers for Medicare & Medicaid Services (CMS) is offering a video tutorial for the assessment of C1310. Signs and Symptoms of Delirium taken from the Confusion Assessment Method (CAM©) which is collected on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) 4.0. This training asset demonstrates a cognitive assessment used to code the items within C1310. 

This resource can be accessed through the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Training page.

December 13, 2023

CMS IRF-PAI Quarterly Q&As, December 2023, Consolidated June 2020 to December 2023

The Centers for Medicare & Medicaid Services (CMS) is publishing the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Quarterly Q&As, in December of 2023. The document contains the consolidated Q&As from June 2020 to December 2023 so that all IRF providers have the benefit of the clarifications to existing guidance. Through inquiries to the IRF Post-Acute Care (PAC) Quality Reporting Program (QRP) Help Desk, CMS identifies the opportunity to clarify or refine guidance.

The Quarterly Q&A document can be accessed via the Downloads section of the IRF-PAI and IRF-PAI Manual webpage.

December 1, 2023

IRF QRP Claims-Based Measure Manual and Accompanying Files– Now Available

The Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Claims-Based Measures Manual and accompanying documents are now available. These documents contain information on how to calculate claims-based measures used in the IRF QRP. 

For more information, please visit the CMS IRF QRP Quality Reporting Measures Information webpage.

November 3, 2023

Reminder of Upcoming Data Submission Deadline

The submission deadline for the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) is approaching. IRF Patient Assessment Instrument (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) 2023 are due with this submission deadline.

All data must be submitted no later than 11:59 p.m. on November 15, 2023.

It is recommended that the applicable Centers for Medicare & Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) 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 CMS Certification Number (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 submission information, visit:

Swingtech sends informational messages to IRFs that are not meeting Annual Increase Factor (AIF) threshold 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@swingtech.com and be sure to include your facility name and CCN along with any requested email updates.

October 16, 2023

NOW AVAILABLE: CMS Post-Acute Care Health Equity Confidential Feedback Reports with Online Webinar and Fact Sheet

As part of our commitment to advance health equity and strengthen the Medicare Program, the Centers for Medicare & Medicaid Services (CMS) have released two Health Equity Confidential Feedback Reports to post-acute care (PAC) providers: the Discharge to Community (DTC) Health Equity Confidential Feedback Report and the Medicare Spending Per Beneficiary (MSPB) Health Equity Confidential Feedback Report. To provide insight on outcome differences across social risk factors, the Health Equity Confidential Feedback Reports stratify these two PAC Quality Reporting Program measure outcomes by Medicare-Medicaid dual-enrollment status (duals and non-duals), as well as patient race/ethnicity (Non-White and White patients). This data is meant to provide feedback to providers about their performance for certain populations who may have been historically disadvantaged. These reports are educational for providers, and to identify opportunities for providers to focus their internal quality improvement initiatives to provide all individuals their best opportunity to achieve their best potential health outcomes.

CMS released the PAC Health Equity Confidential Feedback Reports through the Internet Quality Improvement & Evaluation System (iQIES) reports folders. To locate your Health Equity Confidential Feedback Reports in iQIES, please follow the instructions listed below:

  1. Log into iQIES at https://iqies.cms.gov/ using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) user ID and password. If you do not have a HARP account, you may register for a HARP ID.
  2. From the Reports menu, select My Reports.
  3. From the My Reports page, locate and select the Health Equity Confidential Feedback Reports folder link.
  4. Displayed for you is a list of reports available for download.
  5. Select the report name link to view the Health Equity Confidential Feedback Report data

Additionally, CMS posted an Online Webinar recording with slides, transcript, and Fact Sheet providing an overview of the Health Equity Confidential Feedback Reports on each of the following PAC pages:

October 12, 2023

CMS IRF-PAI Version 4.2

The Centers for Medicare & Medicaid Services (CMS) is publishing the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Version 4.2. The IRF-PAI Version 4.2 will be effective October 1, 2024.

The IRF-PAI Version 4.2 item set can be accessed via the Downloads section of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) and IRF-PAI Manual webpage.

October 2, 2023

Notice of Upcoming IRF QRP Measure Removals

The Centers for Medicare & Medicaid Services (CMS) is alerting Inpatient Rehabilitation Facility (IRF) providers of upcoming measure removals from the IRF Quality Reporting Program (QRP). The following quality measures are planned for removal from the iQIES Review and Correct Reports, Facility-Level Quality Measure (QM) Reports, and Patient-Level QM Reports in January 2024:

  • Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
  • IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients
  • IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients

Once removed from reports, users will no longer have access to any data or measure results for these measures.

These measures will appear in the March 2024 Provider Preview Reports for the June 2024 Refresh of IRF QRP data. Starting with the September 2024 Release, these measures will be removed from Care Compare and Provider Data Catalog. Once removed, the historic publicly reported measure data will continue to be available in the Inpatient Rehabilitation Facilities Data Archive files on the Provider Data Catalog.

Please direct any questions on these measure removals or questions related to quality measures on the IRF QRP Reports to the IRF QRP help desk at IRF.questions@cms.hhs.gov.

Page Last Modified:
03/27/2024 04:16 PM