NOTIFICATION: Fiscal Year (FY) 2016 Payment Update Determination: Two Additional Quality Measures Implemented for the CMS IRF QRP

Fiscal Year (FY) 2016 Payment Update Determination: Two Additional Quality Measures Implemented for the Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility Quality Reporting Program

The Centers for Medicare & Medicaid Services (CMS) retained two measures for FY 2016 payment update determination, as listed below:

Three Quality Measures Retained for FY 2016 Payment Update Determination

• Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (Short-Stay) (NQF #0678) - Collected using the Quality Indicator section of the IRF-PAI
• National Health Safety Network (NHSN) Catheter-associated Urinary Tract Infection (CAUTI) Outcome Measure (NQF #0138) – Collected via Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN)

 Further, CMS began implementation of two additional quality measures for the FY 2016 payment update determination, as listed below. Data collection and submission for these two additional quality measures started on October 1, 2014.

Two Additional Quality Measures Implemented for Fiscal Year 2016 Payment Update Determination

• Percent of Residents or Patients Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine (Short-Stay) (NQF #0680) - Data Collection using the Quality Indicator section of the IRF-PAI
• Influenza Vaccination Coverage Among Healthcare Personnel (HCP) (NQF #0431)- Collected via the CDC’s NHSN

For the purpose of NQF #0680 for FY 2016 payment update determination, IRFs must collect and submit data for any patient who is in the IRF one or more days between October 1, 2014 and March 31, 2015 (2014-2015 influenza vaccination season).  Quality data for this measure should be collected and submitted to the CMS on an ongoing basis, but at least by the established quarterly deadlines. Data collected on patients with one or more days of stay during October 1, 2014 through December 31, 2014, should be submitted/corrected no later than 11:59:59 p.m. on May 15, 2014; data collected on patients with one or more days of stay during January 1, 2015 through March 31, 2015, should be submitted/corrected no later than 11:59:59 p.m. on August 15, 2015.

For the purpose of reporting NQF #0431 summary data for FY 2016 payment update determination, the NHSN guidance and definitions can be found in the NHSN Influenza Vaccination Summary Protocol athttp://www.cdc.gov/nhsn/PDFs/HPS-manual/vaccination/HPS-flu-vaccine-protocol.pdf and athttp://www.cdc.gov/nhsn/PDFs/HCP/Operational-Guidance-IRF-HCP-Flu.pdf. The NHSN protocol provides guidance for IRFs to report HCP influenza vaccination summary data from October 1 (or when the vaccine became available) through March 31, which includes all influenza vaccinations administered during the influenza season at the facility or elsewhere, influenza vaccine declinations, and determinations of a medical contraindication to influenza vaccination. Users must also report associated denominator data for HCP physically working in the inpatient rehabilitation facility for at least 1 working day between October 1 through March 31 of an influenza season, regardless of clinical responsibility or patient contact. Data should be reported separately for employees, licensed independent practitioners, and adult students/trainees and volunteers. Reporting summary data from other contract personnel is optional at this time.

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For further information, please see the CMS IRF QRP website http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/index.html?redirect=/IRF-Quality-Reporting/.