Feb 15, 2019
The Inpatient Rehabilitation Facility (IRF) Provider Threshold Report (PTR) found in the IRF-PAI Provider report category in the CASPER Reporting system has been updated to allow for a rolling year functionality. This functionality allows users to continue to monitor data submissions with existing measures until the report can be enhanced with individual measures or item changes for the current year.
With this new functionality, the report will show ‘0’ (zero) for the “Percent of Assessments Meeting Data Completion Threshold and the Number of Assessments Meeting Data Completion Threshold” for any quality measures that are impacted by updates to the IRF Patient Assessment Instrument (PAI) when the report has not been updated to accommodate the updated or retired items. This means that if a current measure calculation is looking for data in an item that has been retired, the report will display ‘0’ from the date the IRF-PAI was changed until such time that the report can be updated to reflect the item enhancements for the new year.
For example, the IRF PTR calculation for NQF #2631 (Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function) looks for a value item GG0170H1 in the IRF-PAI. However, this item was retired from the IRF-PAI, effective 10/01/2018. Because there is no data for item GG0170H in IRF-PAI records with a Target Date on or after 10/01/2018, the PTR cannot perform the calculations for this measure and a ‘0’ will display for the last quarter of 2018 (CY 18 Q4) on the FY2020 IRF PTR, and also for each quarter on the FY2021 report until the report is updated. CMS will revise this report during calendar year 2019, and once the calculations are updated, the report will correctly display values in the “Percent of Assessments Meeting Data Completion Threshold and the Number of Assessments Meeting Data Completion Threshold” fields. Until that update occurs, measure NQF #2631 will display a zero for reporting periods beginning 10/01/2018 and later.
The measures impacted by the IRF-PAI item changes effective 10/01/2018 are listed below. For each measure, ‘0’ values will display in the “Percent of Assessments Meeting Data Completion Threshold and the Number of Assessments Meeting Data Completion Threshold” fields until the time the IRF PTR is updated to reflect the item set changes.
• Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function (NQF #2631)
• IRF Functional Outcome Measure: Change in Mobility Score for Medical Rehabilitation Patients (NQF #2634)
• IRF Functional Outcome Measure: Discharge Mobility Score for Medical Rehabilitation Patients (NQF #2636)
While CMS realizes that the above measures do not display complete information, the IRF PTR report provides useful information regarding the compliance status for the other quality measures.
If you have any questions concerning this information, please contact the QTSO Help Desk at iqies@cms.hhs.gov or 1 (800) 339-9313.