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
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 website.
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 26, 2023
Register for CMS’ 2023 CMS Health Equity Confidential Feedback Reports Live Q&A
On November 16, 2023 at 2:00 p.m. ET, the Centers for Medicare & Medicaid Services (CMS) will host a live Q&A session regarding the Health Equity Confidential Feedback Reports released on October 16, 2023. The Q&A session will give participants an opportunity to ask and learn about answers to commonly asked questions regarding the report’s methodologies and interpretations from CMS subject matter experts.
Register for the live Q&A session here: https://us06web.zoom.us/webinar/register/WN_CgvglG96SLu7BmfXi60j_Q
Already have questions about the Health Equity Confidential Feedback Reports? Please send questions to CMSHealthEquityCFRSession@ketchum.com by November 2, 2023, for potential inclusion in the Q&A session. Please note that CMS will answer as many questions as time permits and some questions will not be asked verbatim. CMS will post all questions and answers on each of the PAC Training & Education pages sometime after the webinar.
Prepare for the Live Q&A Webinar:
To prepare for the November 16 live Q&A session, please review the October 16, 2023 Online Webinar recording, with slides, a transcript, and a Fact Sheet providing an overview of the Health Equity Confidential Feedback Reports available in the “Downloads” section on each of the following PAC Training & Education pages:
- Home Health Quality Reporting Training & Education webpage.
- Inpatient Rehabilitation Facility Quality Reporting Training & Education webpage.
- Long Term Care Hospital Quality Reporting Training & Education webpage.
- Skilled Nursing Facility Quality Reporting Training & Education webpage.
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:
- 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.
- From the Reports menu, select My Reports.
- From the My Reports page, locate and select the Health Equity Confidential Feedback Reports folder link.
- Displayed for you is a list of reports available for download.
- 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:
- Home Health Quality Reporting Training & Education webpage;
- Inpatient Rehabilitation Facility Quality Reporting Training & Education webpage;
- Long Term Care Hospital Quality Reporting Training & Education webpage; and the
- Skilled Nursing Facility Quality Reporting Training & Education webpage.
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 last 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.
September 22, 2023
NEW RESOURCE AVAILABLE: Understanding Coding for N0415 Explainer Video
A brief explainer video, Understanding Coding for N0415. High-Risk Drug Classes: Use and Indication is now available for IRF Providers. This resource can be accessed through the Inpatient Rehabilitation Facility Quality Reporting Program Training page.
September 20, 2023
CMS IRF-PAI Quarterly Q&As, September 2023, Consolidated June 2020 to September 2023
The Centers for Medicare & Medicaid Services (CMS) is publishing the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Quarterly Q&As, in September of 2023. The document contains the consolidated Q&As from June 2020 to September 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.
September 15, 2023
IRF Provider Preview 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.
For more information, please visit the CMS IRF QRP Public Reportingwebsite.
September 15, 2023
COMING SOON: CMS Health Equity Confidential Feedback Reports
Next month, The Centers for Medicare & Medicaid Services (CMS) will release two new Health Equity Confidential Feedback Reports to 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: the Discharge to Community (DTC) Health Equity Confidential Feedback Report and the Medicare Spending Per Beneficiary (MSPB) Health Equity Confidential Feedback Report. The PAC Health Equity Confidential Feedback Reports will stratify the DTC and MSPB measures by dual-enrollment status and race/ethnicity.
An educational webinar recording and fact sheet providing an overview of the Health Equity Confidential Feedback Reports will also be released next month.
September 12, 2023
IRF QRP Table for Reporting Assessment-Based QM and Standardized Patient Assessment Data Elements and Final Submission Deadlines Affecting FY 2025 and FY 2026 posted
The FY 2024 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Final Rule (88 FR 50956) revised data collection and submission requirements for the IRF Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2025 and FY 2026 QRPs. An update to the IRF QRP Annual Increase Factor (AIF) Table for reporting assessment-based quality measures (QMs) and standardized patient assessment data elements to the Centers for Medicare & Medicaid Services (CMS) affecting FY 2025 AIF determination has been revised and is now available. The changes to the table reflect the data elements that will be required to meet the AIF minimum data completion threshold for the current and final quarters of FY 2025. The IRF QRP Data Collection and Final Submission Deadlines for the FY 2025 IRF QRP has also been revised and is now available.
Additionally, the IRF QRP AIF Table for reporting assessment-based QMs and standardized patient assessment data elements to CMS affecting FY 2026 AIF determination and the IRF QRP Data Collection and Final Submission Deadlines for the FY 2026 IRF QRP are now available.
The revised FY 2025 IRF QRP AIF Table and the FY 2026 IRF QRP AIF Table can be accessed via the Downloads section of the IRF QRP Measures Information webpage. The revised FY 2025 IRF QRP Data Collection and Final Submission Deadlines and the FY 2026 IRF QRP Data Collection and Final Submission Deadlines can be accessed via the Downloads section of the IRF QRP Data Submission Deadlines webpage.
September 12, 2023
IRF QRP FAQs for FY 2024
An update to the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the IRF QRP in Fiscal Year (FY) 2024 and includes other useful resources available to providers.
The FAQ document can be accessed via the Downloads section of the IRF Quality Reporting FAQs webpage.
September 6, 2023
IRF QRP Quality Measure Calculations and Reporting User's Manual V5.0, Change Table, Risk Adjustment Appendix File, Imputation Appendix File, and HCC ICD-10 Now Available
The Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User's Manual Version 5.0 and accompanying documents are now available. These documents serve as an update to the specifications used to calculate quality measures that are included in the IRF QRP effective October 1, 2023.
For more information, please visit the CMS IRF QRP Quality Reporting Measures Information website.
August 8, 2023
NEW RESOURCE AVAILABLE: Social Determinants of Health Items Explainer Video
A brief explainer video, Social Determinants of Health Items: Determining When a Proxy Response is Allowed is now available for IRF Providers. This resource can be accessed through the Inpatient Rehabilitation Facility Quality Reporting Program Training page.
August 4, 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 January March 31 (Q1) of calendar year (CY) 2023 are due with this submission deadline.
All data must be submitted no later than 11:59 p.m. on August 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.
July 27, 2023
Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) and Updates to the Quality Reporting Program (QRP) for FY 2024 (CMS-1781-F)
On July 27, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1781-F) that provides policies for the fiscal year (FY) 2024 Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP). This rule includes two new measures, one measure modification, and three measure removals. The new measures include the Discharge Function Score measure and the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure. CMS is also modifying the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure to report the number of HCP who are up to date with recommended COVID-19 vaccinations per the latest CDC guidance. In addition, CMS is removing three measures including the Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function; the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients; and the IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients. Finally, CMS will begin the public reporting of the Transfer of Health (TOH) Information to the Patient-Post-Acute Care (PAC) and TOH Information to the Provider-PAC measures.
The final rule went on display at the Federal Register and will be available at: https://www.federalregister.gov/public-inspection
July 20, 2023
IRF QRP: Non-Compliance Notifications
The Centers for Medicare & Medicaid Services (CMS) is providing notifications to Inpatient Rehabilitation Facilities (IRFs) that were determined to be out of compliance with IRF Quality Reporting Program (QRP) requirements for calendar year (CY) 2022, which will affect their fiscal year (FY) 2024 Annual Increase Factor (AIF). Non-compliance notifications will be distributed by the Medicare Administrative Contractors (MACs) and will be placed into p My Reports folders in Internet Quality Improvement and Evaluation System (iQIES) on July 20, 2023. Facilities that receive a letter of non-compliance may submit a request for reconsideration to CMS via email no later than 11:59 pm, August 18, 2023. 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.
Please note: Any reconsideration containing protected health information (PHI) will not be processed. All PHI must be removed in order for a reconsideration to be reviewed.
July 14, 2023
UPDATED RESOURCE AVAILABLE: BIMS Video Tutorial
The Centers for Medicare & Medicaid Services (CMS) is offering an updated video tutorial for the Brief Interview for Mental Status (BIMS) which is collected on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) 4.0. This training asset demonstrates the BIMS interview and associated coding.
This resource can be accessed through the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Training page.
June 21, 2023
Care Compare June Refresh of IRF QRP 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).
For more information, please visit the IRF QRP Public Reporting website.
June 21, 2023
CMS IRF-PAI Quarterly Q&As, June 2023, Consolidated June 2020 to June 2023
The Centers for Medicare & Medicaid Services (CMS) is publishing the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) Quarterly Q&As, in June of 2023. The document contains the consolidated Q&As from June 2020 to June 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.
June 15, 2023
IRF Provider Preview 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.
For more information, please visit the CMS IRF QRP Public Reporting website.
May 19, 2023
NEW RESOURCE AVAILABLE: J0510-J0530 Pain Interview Explainer Video
A brief explainer video, J0510-J0530 Pain Interview: Understanding How a Patient Communicates Pain is now available for Inpatient Rehabilitation Facility (IRF) providers. This resource can be accessed through the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Training page.
May 4, 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's (CDC's) National Healthcare Safety Network (NHSN) for October December 31 (Q4) of calendar year (CY) 2022 are due with this submission deadline. The annual NHSN measure Influenza Vaccination among Healthcare Personnel is also due with this deadline.
All data must be submitted no later than 11:59 p.m. on May 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 the 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.
April 3, 2023
IRF PPS for FY 2024;and Updates to the IRF QRP (CMS-1781-P)
On April 3,2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1781-P) that provides proposals for the fiscal year (FY) 2024 Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP). This rule includes two new measure proposals, one measure modification proposal, and three measure removal proposals. The new measure proposals include the Discharge Function Score measure and the COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date measure. CMS is also proposing to modify the COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) measure to report the number of HCP who are up to date with recommended COVID-19 vaccinations per the latest Centers for Disease Control and Prevention (CDC) guidance. In addition, CMS is proposing the removal of three measures including the Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function; the IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients; and the IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients. We are also proposing to begin the public reporting of the Transfer of Health Information to the Patient-Post-Acute Care (PAC) and Transfer of Health Information to the Provider-PAC measures. Finally, we are seeking information on principles for selecting and prioritizing IRF QRP quality measures and concepts and providing an update on p continued efforts to close the health equity gap.
The proposed rule went on display at the Federal Register and will be available at: https://www.federalregister.gov/public-inspection
Page Last Modified:
12/01/2023 08:32 AM