Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Measures and Technical Information

The purpose of this webpage is to provide technical updates and resources related to SNF data collection, submission of quality data, and the Minimum Data Set (MDS). Users may also find contact information on this page for where to direct questions related to technical issues.

This page is updated periodically as updates to technical information, IRF-PAI submission specifications, and reporting tools related to data submission become available.

What are the SNF Quality Reporting Measures?

Measures currently adopted and finalized for the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) are listed below. Data for the SNF QRP measures are collected and submitted through two methods:

  • Minimum Data Set (MDS) 3.0
  • Medicare Fee-For-Service Claims

The following measures are submitted using the MDS 3.0 unless noted otherwise:

SNF 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 fiscal year (FY) 2016 SNF Prospective Payment System (PPS) Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46440). Data collection for this measure began 10/1/2016. Public reporting began 10/24/2018.

SNF QRP Measure #2: 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)

This measure was finalized in the FY 2016 SNF PPS Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46444). Data collection for this measure began 10/1/2016. Public reporting began 10/24/2018.

SNF QRP Measure #3: Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP

This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52014). This is a claims-based measure and no additional data need to be submitted by the SNF. Public reporting began 10/24/2018.

SNF QRP Measure #4: Discharge to Community - PAC SNF QRP

This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52021). This is a claims-based measure and no additional data needs to be submitted by the SNF. Public reporting began 10/24/2018.

SNF QRP Measure #5: Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP

This measure was finalized in the FY 2017 SNF PPS Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52030). This is a claims-based measure and no additional data needs to be submitted by the SNF. Public reporting began 10/24/2019.

SNF QRP Measure #6: Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP

This measure was finalized in the FY 2017 SNF Final Rule which was published in the Federal Register on August 5, 2016 (81 FR 52034). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #7: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36572). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #8: Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients (NQF #2633)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36578). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #9: Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36580). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #10: Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients (NQF #2635)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36583). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #11: Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)

This measure was finalized in the FY 2018 SNF PPS Final Rule which was published in the Federal Register on August 4, 2017 (82 FR 36584). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #12: Transfer of Health Information to the Provider Post-Acute Care

This measure was finalized in the FY 2020 SNF PPS Final Rule which was published in the Federal Register on August 7, 2019 (84 FR 38755). Data collection for this measure is to be determined.

SNF QRP Measure #13: Transfer of Health Information to the Patient Post-Acute Care

This measure was finalized in the FY 2020 SNF PPS Final Rule which was published in the Federal Register on August 7, 2019 (84 FR 38761). Data collection for this measure is to be determined.

Measures Removed from SNF

Percent of Residents or Patients With Pressure Ulcers That Are New or Worsened (Short Stay) (NQF #0678)

This measure was finalized in the FY 2016 SNF PPS Final Rule which was published in the Federal Register on August 4, 2015 (80 FR 46433). Data collection for this measure began10/1/2016. Public reporting began 10/24/2018. As finalized in the FY 2018 SNF PPS Final Rule published in the Federal Register on 08/04/2017 (82 FR 36572), this measure was replaced in the QRP by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 SNF QRP.

For more detailed information on data collection and submission deadlines, please refer to the SNF Quality Reporting Program Data Submission webpage. For more information on the SNF QRP Quality Measure specifications, please reference the SNF QRP Measure Calculations and Reporting User’s Manual in the downloads section of this webpage. For detailed information on MDS 3.0 item sets and coding guidance, please reference the MDS 3.0 RAI Manual webpage on the Nursing Home Quality Initiative website.

Information on the IMPACT Act of 2014 can be found at:

For SNF QRP comments or questions: SNFQualityQuestions@cms.hhs.gov 

Updates:

September 8, 2020

SNF QRP Measure Calculations and Reporting User’s Manual V3.0.1

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Measure Calculations and Reporting User’s Manual Version (V) 3.0.1 and associated risk adjustment appendix and Hierarchical Condition Category (HCC) crosswalks are now available in the downloads section below.

This document serves as an addendum that communicates quality measure updates to the SNF QRP Measure Calculations and Reporting User’s Manual V3.0. The SNF QRP Measure Calculations and Reporting User’s Manual V3.0.1 is effective on October 1, 2020 and provides information on measure-related changes in a change table format in lieu of a complete update to the overall manual. Additionally, we have included the updated Risk Adjustment Appendix File for the SNF QRP Measures Calculations and Reporting User’s Manual V3.0.1, which contains the risk-adjustment values used to calculate the risk-adjusted quality measures, and Crosswalks of ICD-10 codes to HCC categories used in the risk-adjustment models for the Change in Self-Care, Change in Mobility, Discharge Self-Care, and Discharge Mobility measures (NQF #2633, NQF #2634, NQF #2635, and NQF #2636, respectively).

We would like to describe several changes to the quality measure specifications, including updates to the exclusion criteria for the SNF Functional Outcome measures and Discharge to Community measure.

Specification updates for all four SNF Functional Outcome Measures:

  1. Exclusion criteria: The age exclusion criterion for these measures has been updated from 21 years to 18 years, such that any resident younger than 18 years of age will be excluded from measure calculations.

Specification update for the SNF Discharge to Community Measure:

  1. Exclusion criteria: This measure has been updated to exclude residents who had a long-term nursing facility (NF) stay in the 180 days preceding their qualifying hospitalization and SNF stay, with no intervening community discharge between the long-term NF stay and qualifying hospitalization.

June 25, 2020

Update: Release of Revised FY 2022 SNF QRP APU Table for Reporting Assessment-Based Measures and SPADES

On January 30, 2020, the Centers for Medicare & Medicaid Services (CMS) published the Fiscal Year (FY) 2022 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Annual Payment Update (APU) Table for Reporting Assessment-Based Measures and Standardized Patient Assessment Data Elements (SPADES).

Since that time, CMS has delayed the release of the SNF Minimum Data Set (MDS) Version 1.18.0 needed to support the Transfer of Health (TOH) Information Quality Measures and the new or revised SPADEs due to the COVID-19 Public Health Emergency.

CMS has revised the SNF QRP APU table to reflect the updated Data Collection periods and applicable version number. The table has also been updated with new footers to provide additional clarity on the use of the dash (-) for specific items. The revised table can be found in the Downloads section below with the title SNF QRP Table for Reporting Assessment-Based Measures for the FY 2022 SNF QRP APU.

SNF Quality Reporting Program Archives

Page Last Modified:
04/02/2021 09:01 AM