IPFQR Program Rule History

2025

CMS-1806-F

Volume 89

64649

·       Adopted the 30-Day Risk-Standardized All-Cause ED Visit Following an IPF Discharge measure

·       FY 2027 IPFQR Program measure set includes 16 mandatory and one voluntary measure

·       Did not finalize the proposal to modify data submission requirements, beginning with the FY 2027 payment determination, to transition to quarterly data submission for patient-level data

·       Adoption of a sub-regulatory process to incorporate new or revised ICD-10 diagnosis and procedure codes

2024

CMS-1783-P

Volume 88

51098

·       Adopted 4 new measures (Facility Commitment, Screening for SDOH, Screen Positive, and PIX)

·       Modified the COVID-19 Vaccination Coverage Among HCP measure

·       Removed 2 measures (HBIPS-5 and TOB-2/2a)

·       Replaced references to ‘‘QualityNet’’ with ‘‘CMS-designated information system’’

·       Finalized data validation pilot beginning with data submitted in CY 2025 (reflecting care provided during CY 2024)

·       Finalized the sampling requirements for the newly adopted measures

·       Finalized codification of the IPFQR Program requirements governing IPF reporting on quality measures at a new regulation at §412.433 (measure retention and removal policies, procedural requirements for public reporting, ECE policy, and the procedural requirements for participation in the IPFQR Program

2023

CMS-1769-F

Volume 87

·       No changes were made.

2022

CMS-1750-F

Volume 86

42624

·       Adopted 2 new measures (COVID-19 Vaccination Coverage Among HCP and Follow-Up After Psychiatric Hospitalization)

·       Retained the SUB-2/2a and TOB-2/2a measures

·       Removed 2 measures (Timely Transmission of Transition Record and FUH)

·       Changed the term ‘‘Quality Net system administrator’’ with ‘‘QualityNet Security Official”

·       Will no longer require facilities to maintain an active QualityNet security official account to qualify for payment

·       Finalized the voluntary patient-level data reporting for chart- abstracted measures for the FY 2023 payment determination and then to require patient-level data reporting for the FY 2024 payment determination and subsequent years

2021

CMS-1731-F

Volume 85

No changes made

2020

CMS-1712-F

Volume 84

38459

Adopted the Medication Continuation Following Inpatient Psychiatric Discharge measure

2019

CMS-1690-F

Volume 83

38590

·       Adopted the new measure removal Factor 8 (The costs associated with a measure outweigh the benefit of its continued use in the program.)

·       Removed 8 measures (Influenza Vaccination Coverage Among HCP, SUB-1, Assessment of Patient Experience
of Care Measure and Use of an EHR, TOB-3, TOB-3a, HBIPS-2, HBIPS-3)

·       No longer require facilities to report sample size counts for measures for which sampling is performed

2018

Volume 82

38461

·       Established criteria to evaluate measures for retention or removal

·       Changed timeframe specifications for data submission periods and NOP

·       Modified the ECE policy

2017

IPPS Final Rule

CMS 1655

Volume 81

57236

·       Changed the LOS exclusion for the ‘‘Screening for Metabolic Disorders’’ measure to exclude patients with a length of stay => than 365 days, or <= 3 days and delayed the measure implementation until January 1, 2017

·       Adopted 2 new measures (SUB-3/3a and 30-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an IPF)

2016

CMS-1627-F

Volume 80

46694

·       Removed two measures (HBIPS-4 and HBIPS-6)

·       Adopted 5 new measures (TOB-3/3a, SUB-2/2a, and Transition Record with Specified Elements Received by Discharged Patients)

·       Adopted the Screening for Metabolic Disorders measure

·       Required facilities to report data for chart- abstracted measures to the Web-Based Measures Tool on an aggregate basis by year, rather than by quarter, and to discontinue the requirement for reporting by age group

·       Required facilities to report non-measure data as an aggregate, yearly count rather than by quarter

·       Allowed using the Global Initial Patient Population sampling for specific measures

2015

CMS-1606

Volume 79

45961

·       Adopted 6 new measures (Assessment of Patient Experience of Care, Use of an Electronic Health Record, IMM-2, Influenza Vaccination Coverage Among HCP, TOB-1, and TOB-2/2a)

·       Required IPFs to submit to CMS aggregate population counts for Medicare and non-Medicare discharges by age group, diagnostic group, and quarter, and sample size counts for measures for which sampling is performed

·       Adopted the ECE policy and clarified that the use of the term ‘‘exception’’ is synonymous with the term ‘‘waiver”

2014

IPPS Final Rule

CMS-1599

Volume 78

50887

·       Adopted 2 new measures (SUB-1 and FUH) and finalized the FUH measure as a claims-based measure

·       Will publicly display the submitted data on a CMS web site in April of each calendar year following the start of the respective payment determination year (The preview period will be modified to 30 days approximately 12 weeks prior to the public display of the data.)

2013

IPPS Final Rule

CMS-1588

Volume 77

53644

·       Finalized the policy for the application of the payment reduction to the annual update

·       Adopted 6 measures (HBIPS-2, HBIPS-3, HBIPS-4, HBIPS-5, HBIPS-6, and HBIPS-7) to be submitted as aggregate data

·       Will use a sub-regulatory process to make non-substantive updates to NQF-endorsed measures used for the IPFQR Program

·       Finalizing the public display requirements for preview and public display procedures

·       Finalized the population, sampling, and minimum case thresholds

·       Finalized the policy for reconsiderations and appeals

·       Finalized the “waiver” policy

Acronyms

CMS

Centers for Medicare & Medicaid Services

IMM

Immunization

CY

calendar year

IPF

Inpatient Psychiatric Facility

ECE

Extraordinary Circumstance Exception

IPFQR

Inpatient Psychiatric Facility
Quality Reporting

ED

emergency department

LOS

length of stay

EHR

electronic health record

NOP

Notice of Participation

FUH

Follow-Up After Hospitalization for Mental Illness

NQF

National Quality Forum

FY

fiscal year

PIX

Psychiatric Inpatient Experience

HBIPS

Hospital Based Inpatient Psychiatric Services

SDOH

Social Drivers of Health

HCP

healthcare personnel

SUB

Substance Use

ICD

International Classification of Diseases

TOB

Tobacco Treatment