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

The purpose of this webpage is to provide information on the measures reported by SNFs in accordance with the SNF QRP. On this page, you will find descriptions of each measure, links to measure specifications, measure updates and other measure-related information. This page is updated as measure updates become available.

What are the SNF QRP Measures?

Measures adopted for and removed from the SNF QRP are listed below. Several are endorsed by the consensus-based entity (CBE) contracted by the Secretary to guide the selection of performance measures for federal health programs. Data for the SNF QRP measures are collected and submitted through three methods:

• Minimum Data Set (MDS) 3.0
• Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
• Medicare Fee-For-Service Claims

MDS Assessment-Based Measures

Data collected using the MDS 3.0 and submitted to the Centers for Medicare & Medicaid Services (CMS) via the Internet Quality Improvement and Evaluation System (iQIES):

SNF QRP Measure #1: Application of Percent of Residents Experiencing One or More Falls with Major Injury (Long Stay) [CMIT Measure ID #00520 (CBE-endorsed)]

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 through 46444). Data collection for this measure began 10/1/2016. Public reporting began 10/24/2018.

SNF QRP Measure #2: Drug Regimen Review Conducted with Follow-Up for Identified Issues—PAC SNF QRP [CMIT Measure ID #00225 (not endorsed)]

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 through 52039). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #3: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury [CMIT Measure ID #00121 (not endorsed)]

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 through 36577). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #4: Application of IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients [CMIT Measure ID #00404 (not endorsed)]

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 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #5: Application of IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients [CMIT Measure ID #00403 (not endorsed)]

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 through 36593). Data collection for this measure began 10/1/2018. Public reporting began 10/28/2020.

SNF QRP Measure #6: Transfer of Health Information to the Provider-Post-Acute Care [CMIT Measure ID #00728 (not endorsed)]

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 through 38761). Data collection for this measure will begin on October 1, 2023.

SNF QRP Measure #7: Transfer of Health Information to the Patient-Post-Acute Care [CMIT Measure ID #00727 (not endorsed)]

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 through 38764). Data collection for this measure will begin on October 1, 2023.

SNF QRP Measure #8: Discharge Function Score [CMIT Measure ID #01698 (not endorsed)]

This measure was finalized in the FY 2024 SNF PPS rule, which was published on August 10, 2023 (88 FR 21316 through 21422).

SNF QRP Measure #9: COVID-19 Vaccine: Percent of Patients/Residents Who Are Up to Date [CMIT Measure ID #01699 (not endorsed)]

This measure was finalized in the FY 2024 SNF PPS rule, which was published on August 10, 2023 (88 FR 21316 through 21422). Data collection for this measure will begin on October 1, 2025.

For more detailed information on data collection and submission deadlines, please refer to the SNF QRP Data Submission Deadlines webpage. For more information on the data sets and guidance related to the collection and reporting of assessment data, please refer to the MDS Resident Assessment Instrument (RAI) manual located on the MDS 3.0 RAI Manual webpage.

CDC NHSN Measures

Data for these measures are submitted via the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN):

SNF QRP Measure #10:  COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) [CMIT Measure ID #00121 (not endorsed)]

This measure was finalized in the FY 2022 SNF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR 42480 through 42489). Data submission for this measure began October 1, 2021.

SNF QRP Measure #11: Influenza Vaccination Coverage among Healthcare Personnel (HCP) [CMIT Measure ID #00390 (CBE-endorsed)]

This measure was finalized in the FY 2023 SNF PPS Final Rule, which was published in the Federal Register on August 3, 2022 (87 FR 47537 through 47544). Data submission for this measure began October 1, 2022.

Information related to the procedures using the CDC NHSN for data submission for the Influenza Vaccination Coverage among HCP measure can be found on the NHSN website.

For NHSN questions: NHSN@cdc.gov.

Medicare Fee-For-Service Claims-Based Measures

Data for these measures are collected from claims, and no additional data need to be submitted by the SNF.

SNF QRP Measure #12: Medicare Spending Per Beneficiary – Post-Acute Care (PAC) SNF QRP [CMIT Measure ID #00434 (not endorsed)]

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 through 52021). Public reporting began 10/24/2018.

SNF QRP Measure #13: Discharge to Community - PAC SNF QRP [CMIT Measure ID #00210 (CBE-endorsed)]

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 through 52029). Public reporting began 10/24/2018.

SNF QRP Measure #14: Potentially Preventable 30-Day Post-Discharge Readmission Measure – SNF QRP [CMIT Measure ID #00575 (not endorsed)]

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 through 52034). Public reporting began 10/24/2019.

SNF QRP Measure #15: SNF Healthcare-Associated Infections (HAI) Requiring Hospitalization [CMIT Measure ID #00680 (not endorsed)]

This measure was finalized in the FY2022 SNF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR.42473 through 42480). Public reporting began 4/29/2022.

Measures Removed from SNF

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

As finalized in the FY 2018 SNF PPS Final Rule published in the Federal Register on 08/04/2017 (82 FR 36572 through 36577), 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.

Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function

As finalized in the FY2024 SNF PPS rule published on August 10, 2023, this measure was removed from the SNF QRP beginning FY 2024. Data collection for this measure will end on October 1, 2023.

Application of IRF Functional Outcome Measure: Change in Self-Care Score for Medical Rehabilitation Patients

As finalized in the FY2024 SNF PPS rule published on August 10, 2023, this measure was removed from the SNF QRP beginning FY 2024. Data collection for this measure will end on October 1, 2023.

Application of IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients

As finalized in the FY2024 SNF PPS rule published on August 10, 2023, this measure was removed from the SNF QRP beginning FY 2024. Data collection for this measure will end on October 1, 2023.

Updates

December 1, 2023

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

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Claims-Based Measure Manual is now available. The manual serves as a resource used to calculate claims-based measures that are included in the SNF QRP. The SNF DTC, PPR Post-Discharge, and PPR Within-Stay Supplemental Codes file provides both a list of codes used to identify readmission and diagnoses and a list of covariates used in risk adjustment across the DTC, PPR Post-Discharge, and PPR Within-Stay measures. The MSPB-PAC Covariates file provides a list of covariates used in risk-adjustment for the MSPB-PAC measure. Additionally, the MSPB-PAC Clinically Unrelated Services Exclusion file and MSPB-PAC First Day Service Exclusions files provide a list of services that are excluded from MSPB-PAC measure calculation. Finally, the SNF HAI Supplemental Codes file provides both ICD-10 codes used in the measure numerator and covariates used in risk adjustment for the SNF HAI measure.

These files can be accessed in the Downloads section of this webpage.

September 7, 2023

Revised SNF QRP APU Table for FY 2025 and SNF QRP APU Table for FY 2026

The FY 2024 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule (88 FR 53200) revised data collection and submission requirements for the SNF Quality Reporting Program (QRP) affecting the Fiscal Year (FY) 2025 and FY 2026 QRPs.

 A revised table providing the data elements that will be required to meet the Annual Payment Update (APU) minimum data completion threshold for the FY 2025 SNF QRP and the SNF QRP APU Table for reporting assessment-based QMs and standardized patient assessment data elements to CMS affecting FY 2026 APU determination are now available in the Downloads section of this webpage. We also note that the FY 2024 SNF PPS final rule (88 FR 53272) finalized the requirement for SNFs to report 100 percent of the required quality measures data and standardized patient assessment data collected using the MDS on at least 90 percent of all assessments submitted beginning with the FY 2026 QRP (1/1/2024 through 12/31/2024).

September 6, 2023

SNF QRP Quality Measure Calculations and Reporting User’s Manual V5.0, Change Table, Risk Adjustment Appendix File, Imputation Appendix File, and HCC ICD-10 Crosswalks – Now Available

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User’s Manual Version 5.0 is now available. This document serves as an update to the specifications used to calculate quality measures that are included in the SNF QRP. Additionally, the SNF QRP Measure Calculations and Reporting User’s Manual Change Table Version 5.0 is now available. This document provides a summary of measure-related changes between Version 5.0 and Version 4.0 of the SNF QRP Measure Calculations and Reporting User’s Manual specified in change table format. Furthermore, the Risk Adjustment Appendix File for the SNF QRP Measure’s Calculations and Reporting User’s Manual Version 5.0, which contains risk-adjustment values used to calculate the risk-adjusted quality measures, and Crosswalks of Hierarchical Condition Categories (HCC) to International Classification of Diseases (ICD)-10 codes used in risk-adjustment models for the Discharge Self-Care, Discharge Mobility, and Discharge Function Score measures are available. Lastly, the Imputation Appendix File for the SNF QRP Measure’s Calculations and Reporting User’s Manual Version 5.0 is available. This file contains imputed coefficients used to calculate the risk-adjusted quality measures and developed for the new Discharge Function Score measure.

These files are effective October 1, 2023 and can be accessed in the Downloads section of this webpage.

September 1, 2023

SNF QRP Listening Session: Possible Expansion of MDS Data Submission to All SNF Patients Regardless of Payer - Feedback Accepted Through 9/28/2023.

Acumen LLC on behalf of the Centers for Medicare & Medicaid Services (CMS) is accepting feedback on the topics discussed during the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Listening Session held on August 29^th, 2023. The discussion topics are posted in the Downloads section of this webpage for reference. Feedback can be sent to: SNF-listening-session-2023@acumenllc.com, and will be accepted through 5pm ET on September 28, 2023.

September 21, 2022

SNF QRP APU Table for FY 2025

A table providing the data elements that will be required to meet the Annual Payment Update (APU) minimum data completion threshold for the Fiscal Year (FY) 2025 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is available in the Downloads section of this webpage.

September 2, 2022

SNF QRP Quality Measure Calculations and Reporting User’s Manual V4.0, Change Table, Risk Adjustment Appendix File, and HCC ICD-10 Crosswalks – Now Available

The Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Quality Measure Calculations and Reporting User’s Manual Version 4.0 is now available. This document serves as an update to the specifications used to calculate quality measures that are included in the SNF QRP. Additionally, the SNF QRP Measure Calculations and Reporting User’s Manual Change Table Version 4.0 is now available. This document provides a summary of measure-related changes between Version 4.0 of the SNF QRP Measure Calculations and Reporting User’s Manual and Version 3.0.1 of the SNF QRP Measure Calculations and Reporting User’s Manual Addendum specified in change table format. Furthermore, the Risk Adjustment Appendix File for the SNF QRP Measure’s Calculations and Reporting User’s Manual Version 4.0, which contains risk-adjustment values used to calculate the risk-adjusted quality measures, and Crosswalks of Hierarchical Condition Categories (HCC) to International Classification of Diseases (ICD)-10 codes used in risk-adjustment models for the Change in Self-Care, Change in Mobility, Discharge Self-Care, and Discharge Mobility measures [CMIT Measure ID #00402 (not endorsed), CMIT Measure ID #00401 (not endorsed), CMIT Measure ID #00404 (not endorsed), and CMIT Measure ID #00403 (not endorsed), respectively] are available.

These files are effective October 1, 2022, and can be accessed in the Downloads section of this webpage.

SNF Quality Reporting Program Archives