Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Measures Information

The purpose of this webpage is to provide information on the measures reported by IRFs in accordance with the IRF 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 IRF QRP measures?

Measures adopted for and removed from the IRF 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 IRF QRP measures are collected and submitted through three methods:

• Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
• Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN)
• Medicare Fee-For-Service Claims

IRF-PAI Assessment-Based Measures

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

IRF 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 FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47096 through 47100). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #2: IRF Functional Outcome Measure: Discharge Self-Care Score for Medical Rehabilitation Patients [CMIT Measure ID #00404 (CBE-endorsed)]

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47118 through 47119). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #3: IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients [CMIT Measure ID #00403 (CBE-endorsed)]

This measure was finalized in the FY 2016 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2015 (80 FR 47119 through 47120). Data collection for this measure began on October 1, 2016.

IRF QRP Measure #4: Drug Regimen Review Conducted with Follow-Up for Identified Issues–PAC IRF QRP [CMIT Measure ID #00225 (not endorsed)]

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52111 through 52116). Data collection for this measure began on October 1, 2018.

IRF QRP Measure #5: Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury [CMIT Measure ID #00121 (not endorsed)]

This measure was finalized in the FY 2018 IRF PPS Final Rule, which was published on August 3, 2017 (82 FR 36278 through 36283). Data collection for this measure began on October 1, 2018. This measure replaced Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678).

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

This measure was finalized in the FY 2020 IRF PPS Final Rule, which was published in the Federal Register on August 08, 2019 (84 FR 39100 through 39105). Data collection for this measure began on October 1, 2022.

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

This measure was finalized in the FY 2020 IRF PPS Final Rule, which was published in the Federal Register on August 08, 2019 (84 FR 39105 through 39107). Data collection for this measure began on October 1, 2022.

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

This measure was finalized in the FY 2024 IRF PPS Final Rule, which was published on August 2, 2023 (88 FR 51009 through 51023). Data collection for this measure began on October 1, 2023.

IRF 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 IRF PPS Final Rule, which was published on August 2, 2023 (88 FR 51026 through 51035). Data collection for this measure will begin on October 1, 2024.

For more detailed information on data collection and submission deadlines, please refer to the IRF 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 IRF-PAI assessment instrument and specifically Chapter 2 of the IRF-PAI Manual located on the IRF-PAI and IRF-PAI Manual webpage.

CDC NHSN Measures

Data for these measures are submitted via the CDC’s NHSN:

IRF QRP Measure #10: National Healthcare Safety Network (NHSN) Catheter Associated Urinary Tract Infection (CAUTI) Outcome Measure [CMIT Measure ID #00459 (CBE-endorsed)]

This measure was finalized in the Calendar Year (CY) 2013 Hospital Outpatient PPS Final Rule, which was published in the Federal Register on November 15, 2012 (77 FR 68504 through 68505). Data submission for this measure began on October 1, 2012.

IRF QRP Measure #11: National Healthcare Safety Network (NHSN) Influenza Vaccination among Healthcare Personnel [CMIT Measure ID #00390 (CBE-endorsed)]

This measure was finalized in the FY 2014 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2013 (78 FR 47905 through 47906). Data submission for this measure began on October 1, 2014.

IRF QRP Measure #12: National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure [CMIT Measure ID #00462 (CBE-endorsed)]

This measure was finalized in the FY 2015 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2014 (79 FR 45913 through 45914). Data submission for this measure began on January 1, 2015.

IRF QRP Measure #13: COVID-19 Vaccination Coverage among Healthcare Personnel (HCP) [CMIT Measure ID #00180 (not endorsed)]

This measure was finalized in the FY 2022 IRF PPS Final Rule, which was published in the Federal Register on August 4, 2021 (86 FR.42385 through 42396). Data submission for this measure began on October 1, 2021. This measure was modified in the FY 2024 IRF PPS Final Rule, which was published in the Federal Register on August 2, 2023 (88 FR 50999 through 51009).  Data collection for the modified measure began on October 1, 2023.

Medicare Fee-For-Service Claims-Based Measures

The following are Medicare Fee-For-Service Claims-based measures. Because claims-based measures can be calculated using data that have already been submitted to the Medicare program for payment purposes, no additional information collection is required from IRFs.

IRF QRP Measure #14: Medicare Spending per Beneficiary (MSPB)–Post-Acute Care (PAC) IRF QRP [CMIT Measure ID #00434 (CBE-endorsed)]

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52087 through 52095). Data for this measure began with CY 2016 claims data.

IRF QRP Measure #15: Discharge to Community–PAC IRF QRP [CMIT Measure ID #00210 (CBE-endorsed)]

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52095 through 52103). Data for this measure began with CY 2016 claims data.

IRF QRP Measures #16: Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP [CMIT Measure ID #00575 (not endorsed)]

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52103 through 52108). Data for this measure began with CY 2016 claims data.

IRF QRP Measure #17: Potentially Preventable Within Stay Readmission Measure [CMIT Measure ID #00576 (not endorsed)]

This measure was finalized in FY 2017 IRF PPS Final Rule, which was published in the Federal Register on August 5, 2016 (81 FR 52108 through 52111). Data for this measure began with CY 2016 claims data.

Measures Removed from the IRF QRP

1. Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened

As finalized in the FY 2018 IRF PPS Final Rule, which was published in the Federal Register on August 3, 2017 (82 FR 36278 through 36283), this measure was replaced by a modified version of the measure entitled Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury beginning with the FY2020 IRF QRP.

2. Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short Stay)

This measure was finalized for removal in the FY 2019 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2018 (83 FR 38559 through 38560).

3. NHSN Facility-wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure

This measure was finalized for removal in the FY 2019 IRF PPS Final Rule, which was published in the Federal Register on August 6, 2018 (83 FR 38559).

4. All Cause Unplanned Readmission Measure for 30 Days Post-Discharge from Inpatient Rehabilitation Hospitals

As finalized in the FY 2018 IRF PPS Final Rule, which was published in the Federal Register on August 3, 2017 (82 FR 36283 through 36284), this measure was removed beginning with the FY 2019 IRF QRP.

5. Application of Percent of Long-Term Care Hospital Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function

This measure was finalized  for removal in the FY 2024 IRF PPS Final Rule, which was published in the Federal Register on August 2, 2023 (88 FR 51023 through 51024). Data collection for this measure ended on October 1, 2023.

6. IRF Functional Outcome Measure: Change in Self-Care for Medical Rehabilitation Patients

This measure was finalized  for removal in the FY 2024 IRF PPS Final Rule, which was published in the Federal Register on August 2, 2023 (88 FR 51024 through 51026). Data collection for this measure ended on October 1, 2023.

7. IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients

This measure was finalized  for removal in the FY 2024 IRF PPS Final Rule, which was published in the Federal Register on August 2, 2023 (88 FR 51024 through 51026). Data collection for this measure ended on October 1, 2023.

Updates

December 1, 2023

IRF QRP Claims-Based Measures Manual and Accompanying Files – Now Available

The Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) Claims-Based Measures Manual with accompanying supplemental files are now available. The manual serves as a resource used to calculate claims-based measures that are included in the IRF QRP. The Discharge to Community – Post-Acute Care (PAC) IRF QRP (DTC), Potentially Preventable 30-Day Post-Discharge Readmission Measure for IRF QRP (PPR 30 day), and Potentially Preventable Within Stay Readmission Measure for IRFs (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 30 day, and PPR Within Stay measures. The Medicare Spending Per Beneficiary (MSPB)-PAC IRF QRP (MSPB IRF) Covariates file provides a list of covariates used in risk-adjustment for the MSPB IRF measure. Lastly, the MSPB IRF Clinically Unrelated Services Exclusion document and MSPB IRF First Day Service Exclusions files are available. These documents provide a list of services that are excluded from the MSPB IRF measure calculation.

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

September 12, 2023

Revised IRF QRP AIF Table for FY 2025 and IRF QRP AIF Table for FY 2026

The Fiscal Year (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 FY 2025 and FY 2026 QRPs. A revised table providing the data elements that will be required to meet the Annual Increase Factor (AIF) for the FY 2025 IRF QRP and the IRF QRP AIF Table for reporting assessment-based QMs and standardized patient assessment data elements to CMS affecting FY 2026 AIF determination are now available in the Downloads section of this 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 Crosswalks – Now Available

The Inpatient Rehabilitation Facility (IRF) 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 IRF QRP. Additionally, the IRF 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 of the IRF QRP Measure Calculations and Reporting User’s Manual and Version 4.0 of the IRF QRP Measure Calculations and Reporting User’s Manual specified in change table format. Furthermore, the Risk Adjustment Appendix File for the IRF 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 IRF QRP Measure’s Calculations and Reporting User’s Manual Version 5.0 is available. This file contains imputed coefficients used to calculate the new Discharge Function Score measure.

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

IRF Quality Reporting Program Archives