Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Public Reporting

Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Public Reporting

Now available! Our new Provider Data Catalog makes it easier for you to search and download publicly reported data. We’ve also improved Medicare’s compare sites.

Background:

Section 3004(b) of the Affordable Care Act established the IRF QRP. In addition, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the reporting of standardized patient assessment data on quality, resource use, and other measures by Post-Acute Care (PAC) providers, including skilled nursing facilities, home health agencies, IRFs, and long-term care hospitals.

Care Compare

Care Compare formats the reported data to be readily used by the public, which provides a snapshot of the quality of care for each IRF. This tool helps families compare some key quality metrics, such as pressure ulcers and readmissions, for over 1,100 IRFs across the nation.

IRF Provider Preview Reports

Before Quality Measure (QM) data is publicly reported on Care Compare, IRFs have an opportunity to review and correct, as well as preview, their data. A Review and Correct Report is available for providers to access in the Centers for Medicare & Medicaid Services (CMS) reporting system, which will assist them in identifying whether there are any issues with the assessment data already collected and submitted before the applicable quarterly data submission deadlines. The data for the CDC/NHSN measures are not added to the Review and Correct Reports since they are stewarded by the CDC. In lieu of this, the CDC makes accessible to IRFs reports that are similar to the Review and Correct Reports that allow for real-time review of data submissions for all CDC NSHN measures. These are referred to as “CMS Reports” within the “Analysis Reports” page in the NHSN Application. Correction of any errors identified by the facility must be submitted by the final submission deadlines found in the Downloads section of the IRF QRP Data Submission Deadlines webpage.

Following the QRP data submission deadline, a quarterly Provider Preview Report issued by CMS displays the data that will be publicly reported. The purpose of these reports is to give IRFs the opportunity to review their quality measure results on each quality measure prior to public display on Care Compare. Reports are available in the IRF Internet Quality Improvement and Evaluation System (iQIES).

IRFs will have 30 days to preview their quality measure results beginning on the date the reports are available. IRFs reviewing their preview reports will not be able to correct any of the underlying data, as all data submission/correction deadlines for the targeted period will have passed.

An IRF may request CMS review of the data contained within their Provider Preview Report, should they believe the quality measure results to be inaccurate (numerator, denominator or quality metric). All such requests must be made during the 30-day preview period.

Procedures for Requesting CMS Review of an IRF’s Measure Data:

The Centers for Medicare & Medicaid Services (CMS) encourages Inpatient Rehabilitation Facilities (IRFs) to review their data as provided in the preview reports. If an IRF disagrees with performance data (i.e., the numerator, denominator, or quality metric) contained within their preview report, they will have an opportunity to request review of that data by CMS. In order to make such a request, IRF providers must adhere to the process outlined below:

  • Requests for CMS review of data may be submitted to CMS beginning on the day the IRF Provider Preview Reports are available in the IRF Internet Quality Improvement and Evaluation System (iQIES) folders through 11:59:59 p.m. PST on day 30 of the preview period.
  • CMS will not accept any requests for review of data that are submitted after the posted deadline, which falls on the last day of the preview period.
  • IRFs are required to submit their request to CMS via email with the subject line: “[Provider Name] IRF Public Reporting Request for Review of Data” and include their IRF CMS Certification Number (CCN) (e.g., ABC Inpatient Rehabilitation Facility Public Reporting Request for Review of Data, XXXXXX). The request must be sent to the following email address: IRFPRquestions@cms.hhs.gov.
  • The email request must include the following information:
    • IRF CCN
    • IRF Business Name
    • IRF Business Address
    • CEO or CEO-designated representative contact information including: name, email address, telephone number, and physical mailing address, i.e. not a post office box
    • Information supporting the IRF’s belief that the data contained within the IRF’s Provider Preview Report is erroneous including, but not limited to quality measures affected and aspects of quality measures affected (i.e., the numerator, denominator, quality metric)
  • After submitting a request, IRFs will receive an email confirming receipt of their request and may be asked to provide additional information to allow CMS to fully evaluate the request. Such requests from CMS will be sent to the contact person named above.
  • CMS will review all requests and provide a response outlining the decision via email. Please note that IRF-identified errors in data resulting from inaccurate data submissions that an IRF failed to correct prior to the applicable quarterly data submission deadline are not acceptable reasons for granting reconsideration. Also, CMS will not consider correcting quality measure calculations that providers find to be inaccurate due to missing data that was submitted beyond the applicable quarterly data submission deadline.
  • Data that CMS decides/agrees to correct will be corrected and displayed during the subsequent quarterly release of IRF quality data on Care Compare.
  • The data used to generate the IRF Provider Preview Reports are frozen for the upcoming Care Compare refresh, and corrections submitted after the generation of the IRF Provider Preview Report will not be reflected until the next quarterly preview report is generated.

Please note: The only method for submitting a request to CMS for review of your preview report data is via email (IRFPRquestions@cms.hhs.gov). Requests submitted by any other means will not be reviewed. CMS will not review any requests that include protected health information (PHI) or other Health Insurance Portability and Accountability Act (HIPAA) violations in the request being submitted to CMS for review.

To view updated quality data, please visit Care Compare.

Updates

September 27, 2023

Care Compare September Refresh of IRF QRP Data – Now Available

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

The data are based on quality assessment data submitted by IRFs to Centers for Medicare & Medicaid Services (CMS) from Quarter 1, 2022 through Quarter 4, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 4, 2021 through Quarter 3, 2022 for the Clostridium Difficile Infection (CDI) and Catheter-Associated Urinary Tract Infections (CAUTI) measures, Quarter 4, 2021 through Quarter 1, 2022 for the Healthcare Personnel (HCP) Influenza Vaccine measure, and Quarter 4, 2022 for the HCP COVID-19 Vaccine measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022.

In summary, the following IRF QRP measures will be displayed on Care Compare and PDC during the September 2023 Refresh:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay)
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues–PAC IRF QRP
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury
    • Q1 2022 – Q4 2022 (1/1/2022 – 12/31/2022)
  • National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • National Healthcare Safety Network (NHSN) Influenza Vaccination among Healthcare Personnel
    • Q4 2021 – Q1 2022 (10/1/2021 – 3/31/2022)
  • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • National Healthcare Safety Network (NHSN) COVID-19 Vaccination Coverage among Healthcare Personnel
    • Q4 2022 (10/1/2022 – 12/31/2022)
  • Medicare Spending per Beneficiary (MSPB)–Post-Acute Care (PAC) IRF QRP
    • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
  • Discharge to Community–PAC IRF QRP
    • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP
    • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)
  • Potentially Preventable Within Stay Readmission Measure
    • Q4 2020 – Q3 2022 (10/1/2020 – 9/30/2022)

Please visit Care Compare and PDC to view the updated quality data. For questions about IRF QRP Public Reporting, please email IRFPRQuestions@cms.hhs.gov.

September 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 December 2023 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by IRFs from Quarter 2, 2022 through Quarter 1, 2023. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 1, 2022 through Quarter 4, 2022 for the Clostridium Difficile Infection (CDI) and Catheter-Associated Urinary Tract Infections (CAUTI) measures, Quarter 4, 2022 through Quarter 1, 2023 for the Healthcare Personnel (HCP) Influenza measure, and Quarter 1, 2023 for the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022 for this refresh.

Providers have until October 16, 2023 to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Care Compare. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website. However, providers can request Centers for Medicare & Medicaid Services (CMS) review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

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

June 21, 2023

Care Compare June Refresh of IRF QRP Data – Now Available

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

The data are based on quality assessment data submitted by IRFs to the Centers for Medicare & Medicaid Services (CMS) from Quarter 4, 2021 through Quarter 3, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 3, 2021 through Quarter 2, 2022 for the Clostridium Difficile Infection (CDI) and Catheter-Associated Urinary Tract Infections (CAUTI) measures, Quarter 4, 2021 through Quarter 1, 2022 for the Healthcare Personnel (HCP) Influenza Vaccine measure, and Quarter 3, 2022 for the HCP COVID-19 Vaccine measure. The data for the claims-based measures will display data from Quarter 3, 2019 through Quarter 4, 2019 and Quarter 3, 2020 through Quarter 2, 2021.

In summary, the following IRF QRP measures will be displayed on Care Compare and PDC during the June 2023 Refresh:

  • Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) [CMIT Measure ID #00520 (CBE-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function [CMIT Measure ID #00513 (CBE-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients [CMIT Measure ID #00402 (CBE-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients [CMIT Measure ID #00401 (CBE-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients [CMIT Measure ID #00404 (CBE-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients [CMIT Measure ID #00403 (CBE-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Drug Regimen Review Conducted with Follow-Up for Identified Issues–PAC IRF QRP [CMIT Measure ID #00225 (not-endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury [CMIT Measure ID #00121 (not endorsed)]
    • Q4 2021 – Q3 2022 (10/1/2021 – 9/30/2022)
  • National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure [CMIT Measure ID #00459 (CBE-endorsed)]
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • National Healthcare Safety Network (NHSN) Influenza Vaccination among Healthcare Personnel [CMIT Measure ID #00390 (CBE-endorsed)]
    • Q4 2021 – Q1 2022 (10/1/2021 – 3/31/2022)
  • National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure [CMIT Measure ID #00462 (CBE-endorsed)]
    • Q3 2021 – Q2 2022 (7/1/2021 – 6/30/2022)
  • National Healthcare Safety Network (NHSN) COVID-19 Vaccination Coverage among Healthcare Personnel [CMIT Measure ID #00180 (CBE-endorsed)]
    • Q3 2022 (7/1/2022 – 9/30/2022)
  • Medicare Spending per Beneficiary (MSPB)–Post-Acute Care (PAC) IRF QRP [CMIT Measure ID #00434 (CBE-endorsed)]
    • Q3 2019 – Q4 2019 and Q3 2020 – Q2 2021 (7/1/2019-12/31/2019; 7/1/2020-6/30/2021)
  • Discharge to Community–PAC IRF QRP [CMIT Measure ID #00210 (CBE-endorsed)]
    • Q3 2019 – Q4 2019 and Q3 2020 – Q2 2021 (7/1/2019-12/31/2019; 7/1/2020-6/30/2021)
  • Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP [CMIT Measure ID #00575 (not-endorsed)]
    • Q3 2019 – Q4 2019 and Q3 2020 – Q2 2021 (7/1/2019-12/31/2019; 7/1/2020-6/30/2021)
  • Potentially Preventable Within Stay Readmission Measure [CMIT Measure ID #00576 (not endorsed)]
    • Q3 2019 – Q4 2019 and Q3 2020 – Q2 2021 (7/1/2019-12/31/2019; 7/1/2020-6/30/2021)

Please visit Care Compare and PDC to view the updated quality data. For questions about IRF QRP Public Reporting, please email IRFPRQuestions@cms.hhs.gov.

June 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 September 2023 refresh.

The data contained within the Preview Reports are based on quality assessment data submitted by IRFs from Quarter 1, 2022 through Quarter 4, 2022. Additionally, the Centers for Disease Control and Prevention (CDC) measures reflect data from Quarter 4, 2021 through Quarter 3, 2022 for the Clostridium Difficile Infection (CDI) and Catheter-Associated Urinary Tract Infections (CAUTI) measures, Quarter 4, 2021 through Quarter 1, 2022 for the Healthcare Personnel (HCP) Influenza measure, and Quarter 4, 2022 for the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure. The data for the claims-based measures will display data from Quarter 4, 2020 through Quarter 3, 2022 for this refresh.

Providers have until July 17, 2023 to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Care Compare. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on the Care Compare website. However, providers can request Centers for Medicare & Medicaid Services (CMS) review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate.

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

IRF Quality Reporting Archives

Page Last Modified:
09/27/2023 12:20 PM