Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Spotlights & Announcements
Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Spotlights & Announcements
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Updates
December 1, 2023
LTCH QRP Claims-Based Measure Manual and Accompanying Files– Now Available
The Long-Term Care Hospital 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 LTCH QRP.
For more information, please visit the CMS LTCH QRP Quality Reporting Measures Information website.
November 3, 2023
Reminder of Upcoming Data Submission Deadline
The submission deadline for the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) is approaching. LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) assessment data and data submitted via the Centers 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 on the LTCH Quality Reporting Data Submission Deadlines webpage.
For submission information, visit:
Swingtech sends informational messages to LTCHs that are not meeting Annual Payment Update (APU) 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 13, 2023
Reminder: The LTCH QRP Listening Session is scheduled for next week on Tuesday, October 17th from 12:00 PM-1:00 PM ET. Acumen LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) is hosting a public, virtual listening session. On behalf of CMS, we are seeking feedback from administration and management staff, software vendors, and clinical staff on the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) provide burden. If you would like to attend, please register via the WebEx registration link provided in the September 12, 2023 posting on this webpage.
October 12, 2023
CMS LCDS Version 5.1
The Centers for Medicare & Medicaid Services (CMS) is publishing the Long-Term Care Hospital CARE Data Set (LCDS) Version 5.1. The LCDS Version 5.1 will be effective October 1, 2024.
The LCDS Version 5.1 item set can be accessed via the Downloads section of the Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) & LCDS Manual webpage.
October 2, 2023
Notice of Upcoming LTCH QRP Measure Removals
The Centers for Medicare & Medicaid Services (CMS) is alerting Long-Term Care Hospital (LTCH) providers of upcoming measure removals from the LTCH 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:
- Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
- Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function
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 LTCH 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 Long-Term Care Hospitals Data Archive files on the Provider Data Catalog.
Please direct any questions on these measure removals or questions related to quality measures on the LTCH QRP Reports to the LTCH QRP help desk at LTCHQualityQuestions@cms.hhs.gov.
September 27, 2023
Care Compare September Refresh of LTCH QRP Data – Now Available
The September 2023 Refresh of the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).
For more information, please visit the LTCH QRP Public Reporting website.
September 26, 2023
NEW RESOURCE AVAILABLE: BIMS and BIMS Summary Score Explainer Video
A brief explainer video, BIMS and BIMS Summary Score: Stopping and Coding an Incomplete Interview is now available for LTCH Providers. This resource can be accessed through the Long-Term Care Hospital Quality Reporting Program Training page.
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 LTCH Providers. This resource can be accessed through the Long-Term Care Hospital Quality Reporting Program Training page.
September 20, 2023
CMS LCDS Quarterly Q&As, September 2023, Consolidated September 2020 to September 2023
The Centers for Medicare & Medicaid Services (CMS) is publishing the Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) Quarterly Q&As, in September of 2023. The document contains the consolidated Q&As from September 2020 to September 2023 so that all LTCH providers have the benefit of the clarifications to existing guidance. Through inquiries to the LTCH 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 LTCH CARE Data Set and LCDS Manual webpage.
September 19, 2023
LTCH QRP Table for Reporting Assessment-Based QM and Standardized Patient Assessment Data Elements and Data Collection and Final Submission Deadlines Affecting FY 2025 and FY 2026 posted
The FY 2024 Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Final Rule (88 FR 58640) revised data collection and submission requirements for the LTCH Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2025 and FY 2026 QRPs. An update to the LTCH QRP Annual Payment Update (APU) 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 APU determination has been revised and is now available. The changes to the table reflect the data elements that will be required to meet the APU minimum data completion threshold for the current and final quarters of FY 2025. The LTCH QRP Data Collection and Final Submission Deadlines for the FY 2025 LTCH QRP has also been revised and is now available.
Additionally, the LTCH QRP APU Table for reporting assessment-based QMs and standardized patient assessment data elements to CMS affecting FY 2026 APU determination and the LTCH QRP Data Collection and Final Submission Deadlines for the FY 2026 LTCH QRP are now available. We also note that the FY 2024 LTCH PPS final rule (88 FR 58640) finalized the requirement for LTCHs to report 100 percent of the required quality measures data and standardized patient assessment data collected using the LCDS on at least 85 percent of all assessments submitted beginning with the FY 2026 QRP (1/1/2024 through 12/31/2024).
The revised FY 2025 LTCH QRP APU Table and the FY 2026 LTCH QRP APU Table can be accessed via the Downloads section of the LTCH QRP Measures Information webpage. The revised FY 2025 LTCH QRP Data Collection and Final Submission Deadlines and the FY 2026 LTCH QRP Data Collection and Final Submission Deadlines can be accessed via the Downloads section of the LTCH QRP Data Submission Deadlines webpage.
September 15, 2023
LTCH Provider Preview Reports – Now Available
The Long-Term Care Hospital (LTCH) 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 LTCH QRP Public Reporting website.
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 14, 2023
LTCH QRP FAQs for FY 2024
An update to the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the LTCH 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 LTCH Quality Reporting FAQs webpage.
September 12, 2023
REGISTRATION OPEN: LTCH QRP Listening Session:
Date/Time: Tuesday, October 17th from 12pm-1:00pm ET
Registration Link: Registration can be completed online through Webex.
Acumen LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) is hosting a public, virtual listening session. On behalf of CMS, we are seeking feedback from industry stakeholders on the current reporting requirements in the Long-Term Care Hospital (LTCH) quality reporting programs (QRP). The goal of this listening session is for CMS to continue exploring how administrative burden on LTCHs can be further addressed. Space is limited to the first 1,000 registrants.
Prior to the listening session, you are encouraged to prepare to speak to the following topics during the call:
- Reporting burden of the LTCH QRP, including the addition and removal of LTCH QRP data elements and measures
- Utility of the current measures in the LTCH QRP
- LTCHs use of electronic health records (EHRs) in their work flow and the potential use of Fast Healthcare Interoperability Resources (FHIR) to reduce burden for data exchange and information sharing
- Provider education needs
September 6, 2023
LTCH QRP Quality Measure Calculations and Reporting User’s Manual V5.0, Change Table, Risk Adjustment Appendix File, and Imputation Appendix File – Now Available
The Long-Term Care Hospital (LTCH) 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 LTCH QRP effective October 1, 2023.
For more information, please visit the CMS LTCH 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 LTCH Providers. This resource can be accessed through the Long-Term Care Hospital Quality Reporting Program Training page.
August 4, 2023
Reminder of Upcoming Data Submission Deadline
The submission deadline for the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) is approaching. LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) assessment data and data submitted via the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) for January 1 – 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 on the LTCH Quality Reporting Data Submission Deadlines webpage.
For submission information, visit:
Swingtech sends informational messages to LTCHs that are not meeting Annual Payment Update (APU) 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.
August 1, 2023
Long Term Care Hospital (LTCH) Prospective Payment system (PPS) and Updates to the Quality Reporting Program (QRP) for FY 2024 IPPS/LTCH PPS Final Rule (CMS-1785-F)
On August 1, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1785-F) that provides policies for the fiscal year (FY) 2024 Long Term Care Hospital Quality Reporting Program (LTCH QRP). This final rule includes two new measures, one measure modification, and two 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 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 of two 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. Furthermore, we are changing to the data completion thresholds for the LCDS data items and to begin the public reporting of the Transfer of Health Information to the Patient-Post-Acute Care and Transfer of Health Information to the Provider-PAC measures Finally, we provide a summary of the comments received for selecting and prioritizing LTCH QRP quality measures and concepts and the update on CMS’ continued efforts to close the health equity gap.
The final rule went on display at the Federal Register and is available at: https://www.federalregister.gov/public-inspection
July 20, 2023
LTCH QRP: Non-Compliance Notifications
CMS is providing notifications to Long-Term Care Hospitals (LTCHs) that were determined to be out of compliance with LTCH Quality Reporting Program (QRP) requirements for calendar year (CY) 2022, which will affect their fiscal year (FY) 2024 Annual Payment Update (APU). Non-compliance notifications will be distributed by the Medicare Administrative Contractors (MACs) and will be placed into facilities’ My Reports folders in the 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 LTCH 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
NEW RESOURCE AVAILABLE: BIMS Video Tutorial
The Centers for Medicare and Medicaid (CMS) is offering a new video tutorial for the Brief Interview for Mental Status (BIMS) which is now collected on the LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) 5.0. This training asset demonstrates the BIMS interview and associated coding.
This resource can be accessed through the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Training page.
June 21, 2023
Care Compare June Refresh of LTCH QRP Data – Now Available
The June 2023 Refresh of the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC).
For more information, please visit the LTCH QRP Public Reporting website.
June 21, 2023
CMS LCDS Quarterly Q&As, June 2023, Consolidated September 2020 to June 2023
The Centers for Medicare & Medicaid Services (CMS) is publishing the Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) Quarterly Q&As, in June of 2023. The document contains the consolidated Q&As from September 2020 to June 2023 so that all LTCH providers have the benefit of the clarifications to existing guidance. Through inquiries to the LTCH 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 LTCH CARE Data Set and LCDS Manual webpage.
June 15, 2023
LTCH Provider Preview Reports – Now Available
The Long-Term Care Hospital (LTCH) 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 LTCH 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 Long-Term Care Hospital (LTCH) providers. This resource can be accessed through the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) Training page.
May 4, 2023
Reminder of Upcoming Data Submission Deadline
The submission deadline for the Long-Term Care Hospital (LTCH) Quality Reporting Program (QRP) is approaching. LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) assessment data and data submitted via the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) for October 1 – 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 LTCH Quality Reporting Data Submission Deadlines webpage.
For submission information, visit:
Swingtech sends informational messages to LTCHs that are not meeting the Annual Payment Update (APU) 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 10, 2023
LTCH PPS and Updates to the QRP for FY 2024 IPPS/LTCH PPS Proposed Rule (CMS-1785-P).
On April 10, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1785-P) that provides proposals for the fiscal year (FY) 2024 Long Term Care Hospital Quality Reporting Program (LTCH QRP). This rule includes two new measure proposals, one measure modification proposal, and two 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 measure (CBE #3636) to report the number of HCP who are up to date with recommended COVID-19 vaccinations per the latest The Centers for Disease Control and Prevention (CDC) guidance. In addition, CMS is proposing the removal of two 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. Furthermore, we are proposing changes to the data completion thresholds for the LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) data items and to begin the public reporting of the Transfer of Health Information to the Patient-Post-Acute Care and Transfer of Health Information to the Provider-PAC measures Finally, we are seeking information on principles for selecting and prioritizing LTCH QRP quality measures and concepts and providing an update on CMS’ continued efforts to close the health equity gap.
The proposed rule went on display at the Federal Register and is available at: https://www.federalregister.gov/public-inspection
Page Last Modified:
12/01/2023 08:33 AM