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

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

The Centers for Medicare & Medicaid Services (CMS) has many sources of information about the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) for hospitals and other stakeholders including:

  • Training Materials and In-person Training
  • Training Question and Answers (Q&As)
  • Hospital/Quality Initiative Open Door Forum (ODF) Presentations
  • Special Open Door Forum (SODF) Presentations
  • CMS Quality Partner/Vendor Workgroup Presentations

This page is organized to be a library of training materials available to IRFs. Trainings added to this page in the most recent six months will display as *NEW*.

If you have technical questions or feedback regarding the training, please email the PAC Training mailbox. Content-related questions should be submitted to the IRF QRP Help Desk.

Introduction to the IRF QRP Web-Based Training

This web-based training course was developed for those who are new to the IRF QRP. The Introduction to the IRF QRP course is designed to provide a general overview of the program as well as a variety of links and resources for additional information. Specific topics include:

  • Lesson 1: What is the IRF QRP?
  • Lesson 2: The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)
  • Lesson 3: IRF-PAI Data Submission
  • Lesson 4: IRF QRP Resources

From Data Elements to Quality Measures – Cross-Setting QRP Web-Based Training.

This web-based training course provides a high-level overview of how data elements within CMS patient/resident assessment instruments are used to construct quality measures (QMs) across post-acute care (PAC) settings. The PAC settings included are those covered under the CMS QRPs for Home Health Agencies (HHAs), IRFs, Long-Term Care Hospitals (LTCHs) and Skilled Nursing Facilities (SNFs). Information covered in this 60-minutes course will include a brief review of the QRPs’ cross-setting QMs, how data elements feed into these cross-setting QMs, how QMs are calculated and appear on QM reports and how to access and use this data for quality improvement.

Achieving a Full AIF Webinar

A video of the IRF QRP: Achieving a Full Annual Increase Factor (AIF) webinar that took place on Wednesday, May 19, 2021, is available to view on YouTube at the following link: https://youtu.be/Jk2_2tqwg88. The training materials are here:

*NEW* What You Need to Know: PAC QRP Key Program Updates – FY/CY 2025 Web-Based Training

This web-based training course provides an overview of key updates to the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program (QRP) for Fiscal Year (FY) 2025. This targeted training discusses new, removed, and revised quality measures, timelines for public reporting, and measure specifications. In addition, assessment guidelines and coding instructions are presented for two new data elements: O0350. Patient’s COVID-19 vaccination is up to date and A1400. Payer Information. To access the training, click on the following link:

Social Determinants of Health Training Materials

SDOH Items Explainer Video

The Social Determinants of Health (SDOH) Items: Determining When a Proxy Response is Allowed for IRF Providers 4-minute explainer video was developed to assist providers in accurately determining when the use of a proxy response is allowed for SDOH items: A1005. Ethnicity, A1010. Race, A1110. Language, A1250. Transportation, B1300. Health Literacy, and D0700. Social Isolation. 

Section A Training Materials

Transfer of Health Items Explainer Video

This short, animated explainer video is intended to assist providers in coding A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge and A2123. Provision of Current Reconciled Medication List to Patient at Discharge.

Section C Training Materials

Cognitive Assessment

This web-based training provides an overview of the approaches to conducting a standardized cognitive assessment and the Brief Interview for Mental Status (BIMS). The course includes interactive exercises to evaluate your knowledge related to the assessment and coding of the BIMS and should take approximately 45 minutes to complete.

BIMS Video Tutorial

This 10-minute updated video tutorial was developed to assist providers with guidance application and interview strategies for the cognitive assessment known as the Brief Interview of Mental Status (BIMS) found in the IRF-PAI 4.0. This video tutorial is designed to provide targeted guidance for accurate coding using live-action patient scenarios. 

BIMS and BIMS Summary Score Explainer Video

This animated explainer video, BIMS and BIMS Summary Score: Stopping and Coding an Incomplete Interview for IRF Providers was developed to assist providers in accurately determining when the Brief Interview of Mental Status (BIMS) should be stopped, and how to code the remaining items in this situation. 

BIMS Interview Cue Cards

This set of cue cards is intended to assist providers in conducting the Brief Interview of Mental Status (BIMS), as referenced in the IRF-PAI 4.0 coding guidance. This resource is intended to be utilized as a supplemental patient communication tool that provides a visual reference for the coding of response options. More detailed instructions regarding the use of cue cards and the administration of the BIMS in writing can be found in the IRF-PAI 4.0 Manual.

Section D Training Materials

PHQ-2 to 9 Cue Card

This cue card is intended to assist providers in coding the Patient Health Questionnaire (PHQ-2 to 9) as referenced in the coding guidance for D0150. This resource is intended to be utilized during the Patient Mood Interview as a supplemental communication tool that provides a visual reference to assist patient selection of symptom frequency. The cue card is offered in two sizes which can be viewed or printed here:

*NEW* Patient Mood Interview (Patient Health Questionnaire PHQ-2 to 9©) Video Tutorial

This video tutorial depicts two scenarios that demonstrate the coding of the PHQ-2 to 9 for the purposes of completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. Two patient vignettes are depicted, one in which the PHQ-2 is demonstrated and one in which the entire PHQ-2 to 9 is completed. This video can be viewed through the following link:

*NEW* Confusion Assessment Method (CAM©) Video Tutorial

The Centers for Medicare & Medicaid Services (CMS) is offering a video tutorial to assist providers with guidance application and assessment strategies for C1310. Signs and Symptoms of Delirium taken from the Confusion Assessment Method (CAM©) found in the IRF-PAI 4.0. This video tutorial is approximately 14 minutes in length and is designed to provide targeted guidance for accurate coding using a live-action patient scenario. 

Video Tutorials Available to Assist with Coding Specific Section GG Items

These videos, ranging from 4 to 12 minutes, are designed to provide targeted guidance using simulated patient scenarios. To access the videos, click on the links below.

Section J Training Materials

Health Conditions: Coding the Standardized Patient Assessment Data Elements Related to Falls

This 45-minute web-based training provides an overview of the assessment and coding of the standardized patient assessment data elements in Section J: Health Conditions and is designed to include interactive exercises to evaluate your knowledge. To access the videos, click the links below.

J0510-J0530 Pain Interview Explainer Video

This 4-minute, animated explainer video, J0510-J0530 Pain Interview: Understanding How a Patient Communicates Pain for IRFs was developed to assist providers in accurately coding the new pain interview items including pain assessment strategies and associated patient communication challenges. The video is now available through the following link: J0510-J0530 Pain Interview Explainer Video.

Pain Interview Cue Cards

This set of cue cards is intended to assist providers in conducting the Pain Interview, as referenced in the IRF-PAI 4.0 coding guidance. This resource is intended to be utilized as a supplemental patient communication tool that provides a visual reference for the coding of response options. More detailed instructions regarding the use of cue cards can be found in the IRF-PAI 4.0 Manual.

Section M Training Materials

Assessment and Coding of Pressure Ulcers/Injuries

This 90-minute web-based training provides an overview of the assessment and coding of the standardized patient assessment data elements in Section M: Skin Conditions and is designed to include interactive exercises to evaluate your knowledge. To access the videos, click the links below.

Section N Training Materials

Medications – Drug Regimen Review

This 45-minute web-based training provides an overview of the assessment and coding of the Drug Regimen Review standardized patient assessment data elements to Section N and is designed to be used on demand anywhere you can access a browser. To access the videos, click the links below.

Understanding Coding for N0415 Explainer Video

This 4-minute, animated explainer video, Understanding Coding for N0415. High-Risk Drug Classes: Use and Indication for IRF Providers, was developed to assist providers in accurately determining whether a patient is taking any prescribed medications in the specified drug classes and whether the patient-specific indication was noted for all medications in the drug class. 

Job Aids

Companion job aids assist providers in the assessment and coding of assessment items, and provide clinically relevant information to assist providers in understanding specific guidelines and clinical considerations that should be applied to coding these items. The job aids are provided in multiple file types designed for printing, viewing, or sharing electronically. An explanation of the file types is provided in the ZIP file.

GG0130A. Eating, GG0130B. Oral Hygiene, GG0130C. Toileting Hygiene, GG0130E. Shower/Bathe Self, GG0130F. Upper Body Dressing, GG0130G. Lower Body Dressing, and GG0130H. Putting On/Taking Off Footwear

Pocket Guides / Badge Buddies

Pocket Guides are intended to assist providers in the assessment and coding of assessment items, and provide a quick reference for important terms and definitions that promote coding accuracy. These pocket guides are approximately 2 x 3.5 inches in size and are designed to be worn behind a provider identification badge.

Health Equity Confidential Feedback Reports Educational Materials

CMS released an educational webinar recording and fact sheet providing an overview of the Health Equity Confidential Feedback Reports that were released in October 2023.  They also hosted a live Q&A session to answer questions about the report. To access the materials, click the links below.

Updates

October 17, 2024

NOW AVAILABLE: Updated Annual DTC and MSPB Health Equity Confidential Feedback Reports for Post-Acute Care Providers with Educational and Outreach Materials 

On October 15, 2024, the Centers for Medicare & Medicaid Services (CMS) updated the two annual post-acute care (PAC) Health Equity Confidential Feedback Reports: the Discharge to Community (DTC) Health Equity Confidential Feedback Report and the Medicare Spending Per Beneficiary (MSPB) Health Equity Confidential Feedback Report. 

These reports are available through the Internet Quality Improvement & Evaluation System (iQIES) reports folders to providers in the Home Health (HH), Inpatient Rehabilitation Facility (IRF), Long-Term Care Hospital (LTCH), and Skilled Nursing Facility (SNF) settings. The updated Fall 2024 Health Equity Confidential Reports are based on data from Calendar Year 2022-2023 for HH and from Fiscal Year 2022-2023 for IRF, LTCH, and SNF settings. 

To locate your updated Fall 2024 Health Equity Confidential Feedback Reports in iQIES, please follow the instructions listed below:

  1. Log into iQIES 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.
  2. From the Reports menu, select My Reports.
  3. From the My Reports page, locate and select the Health Equity Confidential Feedback Reports folder link.
  4. Displayed for you is a list of reports available for download.
  5. Select the report name link to view the Health Equity Confidential Feedback Report data

CMS has developed the following educational and outreach materials to support providers in accessing and understanding their updated annual DTC and MSPB Health Equity Confidential Feedback Reports that are available in the Downloads section below: 

October 15, 2024

NEW RESOURCES AVAILABLE: Educational Webinar and Fact Sheet for the Screen Positive for Health-Related Social Needs Indicator Confidential Feedback Report for HH, IRF, and LTCH

On October 15, 2024, the Centers for Medicare & Medicaid Services (CMS) released the new Screen Positive for Health-Related Social Needs (HRSN) Indicator Confidential Feedback Report to Home Health (HH), Inpatient Rehabilitation Facility (IRF), and Long-Term Care Hospital (LTCH) providers.1 This report presents summary information for your patient population on four HRSN data elements: Health Literacy, Need for Interpreter Services, Social Isolation, and Transportation. Results for this initial report are calculated using data from October 1, 2023 – September 30, 2024, and will be updated quarterly based on the most recent 12 months of available data.

This report is provider-generated in the Internet Quality Improvement & Evaluation System (iQIES). To generate your Fall 2024 Screen Positive for HRSN Indicator Confidential Feedback Report in iQIES, please follow the instructions listed below:

  1. Log into iQIES at https://iqies.cms.gov/iqies 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.
  2. From the ‘Reports’ tab, select the option for ‘Find a Report’.
  3. Select the Report Category of ‘Health Equity’ and Report Type of ‘Health-Related Social Need Indicator’. 
  4. Displayed for you is a list of reports available for download. Select the ‘Screen Positive for Health-Related Social Need Indicator Report’ link OR the ‘Run Report’ option to view the report.
  5. The reports filter page displays with the specific filter criteria required for this HRSN report: Provider and Date Range. 
    • For the Provider filter, search for up to 25 providers by Provider Name, CMS Certification Number (CCN), or Facility ID and add each provider to the filter selection. 
    • For the Date Range filter, the system defaults to the latest quarter end date available and allows users to select prior quarter end dates. Select the desired End Date Range.
  6. Select the ‘Run Report’ button at the bottom of the page. 

To support providers in accessing and understanding this new report, CMS has released an educational webinar recording and the related webinar slides and transcript. We also released a fact sheet that provides an overview of the Screen Positive for HRSN Indicator Confidential Feedback Report. To access the webinar recording video, click on the following link: Online webinar recording. The webinar slides, webinar transcript, and fact sheet are available in the Downloads section below. 

1 CMS plans to release this report to Skilled Nursing Facility providers in October 2025, when a full Fiscal Year of data (October 1, 2024 – September 30, 2025) will become available for the first time.

September 4, 2024

UPDATED RESOURCE AVAILABLE: From Data Elements to Quality Measures Cross-Setting Web-Based Training

The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides a high-level overview of how data elements within CMS patient/resident assessment instruments are used to construct quality measures (QMs) across post-acute care (PAC) settings. The course also discusses the relationship between these data elements and Quality Reporting Program (QRP) QMs, QM calculation, and how to access reports and use QM data for quality improvement. To access the training, click on the following link: From Data Elements to Quality Measures: Cross-Setting Web-Based Training

If you have questions about accessing resources or feedback regarding trainings, please email the PAC Training Mailbox. Content-related questions should be submitted to the IRF QRP Help Desk.

August 26, 2024

UPDATED RESOURCE AVAILABLE: Section GG Web-Based Training Series

The Centers for Medicare & Medicaid Services (CMS) is offering an updated series of web-based training courses that provide an overview of the assessment and guidance to promote accurate coding of the post-acute care (PAC) cross-setting Section GG data elements. Each course contains interactive exercises to test your understanding. To access the courses, click on the links below:

If you have questions about accessing resources or feedback regarding trainings, please email the PAC Training Mailbox. Content-related questions should be submitted to the IRF QRP Help Desk.

August 14, 2024

NOW AVAILABLE: CMS National Summary Report, Executive Summary, and National Summary Results workbook for the 2023 Post-Acute Care Health Equity Confidential Feedback Reports 

In October 2023, the Centers for Medicare & Medicaid Services (CMS) 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 help expand access to aggregate stratified results, the National Summary Report provides insights on aggregate (e.g., national-level) differences in quality by dual-enrollment status and race/ethnicity in the PAC settings. This report can be used as a reference by PAC providers who received the 2023 Health Equity Confidential Feedback Reports. In addition, this report can help other stakeholders understand aggregate variations in the stratified DTC and MSPB measure outcomes. The Executive Summary of the National Summary Report serves as a quick summary of the main findings from the National Summary Report. The National Summary Results workbook includes the full set of results that were included in the National Summary Report. 

The National Summary Report, Executive Summary, and National Summary Results workbook can be found in the Downloads section of the PAC QRP Training webpage for HH, IRF, LTCH, and SNF.

July 24, 2024

NEW RESOURCE AVAILABLE:  Patient Mood Interview (Patient Health Questionnaire PHQ-2 to 9©) Video Tutorial

The Centers for Medicare & Medicaid Services (CMS) is offering a video tutorial for completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. This video depicts two scenarios that demonstrate the coding of the PHQ-2 to 9 for the purposes of completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. Two patient vignettes are depicted, one in which the PHQ-2 is demonstrated and one in which the entire PHQ-2 to 9 is completed. This video can be viewed through the following link: https://youtu.be/_JU7ABmbBGA.

If you have questions about accessing resources or feedback regarding trainings, please email the PAC Training Mailbox. Content-related questions should be submitted to the IRF QRP Help Desk.

July 19, 2024

NEW RESOURCE AVAILABLE: What You Need to Know: PAC QRP Key Program Updates – FY/CY 2025 Web-Based Training

The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of key updates to the Inpatient Rehabilitation Facility (IRF) Quality Reporting Programs (QRP) for Fiscal Year (FY) 2025. This targeted training discusses new, removed, and revised quality measures, timelines for public reporting, and measure specifications. In addition, assessment guidelines and coding instructions are presented for two new data elements: O0350. Patient’s COVID-19 vaccination is up to date and A1400. Payer Information. To access the training, click on the following link: FY/CY 2025 Web-Based Training.

If you have questions about accessing resources or feedback regarding trainings, please email the PAC Training Mailbox. Content-related questions should be submitted to the IRF QRP Help Desk.

 

IRF Quality Reporting Program Archives

Downloads

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11/29/2024 11:19 AM
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