2024 IPFQR Reporting Requirements

The Inpatient Psychiatric Facility Quality Reporting (IPFQR) Program is a pivotal initiative by the Centers for Medicare & Medicaid Services (CMS) designed to enhance the quality of care in Inpatient Psychiatric Facilities (IPFs). Measures submitted to CMS are publicly reported on the CMS Care Compare website to equip consumers with quality-of-care information to make more informed decisions about their healthcare reporting options.

It’s important for facilities to understand the 2024 reporting requirements to ensure they don’t fail a submission deadline. As always, we are here to help with a step-by-step guide to everything you need to do to ensure a successful 2024 IPFQR reporting year. This article explores what's new and what's changed and how your facility can not only comply with the new requirements but also excel in delivering high-quality patient care.

Take a minute to read through it, then contact us if you have any questions.

Who is Eligible To Report to the IPFQR program and What’s at Risk?

The IPFQR program (like the IQR and OQR programs) is a pay-for-reporting program. All IPFs paid under the Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) must meet all reporting requirements. Failure to meet these requirements will result in a two-percentage point reduction to a facility’s Annual Payment Update (APU) for Fiscal Year (FY) 2026. The IPF PPS applies to inpatient psychiatric services given by psychiatric hospitals or separately licensed psychiatric units (Also known as mental health or behavioral health units) in these settings: Acute Care, Critical Access, Long-Term Care, Inpatient Rehabilitation Facilities, and Children’s Hospitals.

CMS also publishes hospitals’ measure results on Care Compare as a means of helping consumers choose which hospitals to go to for their care. So, it’s not just money that’s on the line—it’s your brand image and reputation.

Summary of Changes to the IPFQR Requirements

The 2024 IPFQR Program introduces significant changes that impact the way data is reported, including the adoption of new measures and the modification of existing ones.

NEW Mandatory Measures

• The Facility Commitment to Health Equity (FCHE) measure

NEW Voluntary Measures (Required in CY 2025)

• Social Drivers of Health (SDOH): Screening for Social Drivers of Health (SDOH-1)
• Screen Positive Rate for Social Drivers of Health (SDOH-2)

MODIFIED Required Measures

• The COVID-19 Vaccination Coverage Among Healthcare Personnel measure has been updated to align with the latest CDC guidelines, reflecting the availability, and FDA authorization, of Moderna and Pfizer-BioNTech COVID-19 vaccines for use as booster doses, beginning with fourth quarter CY 2023 data for the FY 2025 payment determination and each quarter thereafter.

REMOVED Measures (beginning January 1, 2023)

• HBIPS-5 – Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification
• TOB-2/2a - Tobacco Use Brief Intervention Provided or Offered and Tobacco Use Brief Intervention Provided

2024 IPFQR Requirements Summary

Before an IPF can meet the requirements of the IPFQR Program, a representative from the IPF must register and maintain an active HARP Security Official (SO) account in the Hospital Quality Reporting (HQR) Secure Portal. To receive the full APU, IPFs must adhere to all three of the following requirements:

• Complete the IPFQR NOP, indicating participation status.
• Collect and submit patient-level measure data and aggregate non-measure data during the reporting period and by the annual submission deadline.
• Complete the DACA by the annual submission deadline, to electronically acknowledge that the data submitted for the IPFQR Program is accurate and complete.

These mandatory requirements are due quarterly:

• Submit one NHSN measure (COVID-19 Vaccination HCP)

These mandatory requirements are due annually:

• Submit data for four non-measures
• Submit 11 Abstracted Measures
• Attest to one Structural Measure
• Complete the DACA (Data Accuracy and Completeness Acknowledgement)

You must also:

• Regularly review your claims-based data
• Consider voluntarily submitting the SDOH-1 and SDOH-2 measures
  
  

1. Submit Non-Measure Data Annually

	REQUIREMENT: Facilities must report a full year of facility-level data for the four mandatory non-measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

The submission of non-measure data must include total annual discharges and annual discharges by age strata, primary diagnosis, and payer.

2. Submit Chart-Abstracted Measures Annually

	REQUIREMENT: Facilities must report a full year of clinical data for the eleven mandatory abstraction measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

3. Attest to One Structural Measure Annually

	REQUIREMENT: Facilities must attest to the one structural measure.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

4. Submit NHSN Measures Quarterly

	REQUIREMENT: Facilities must report four quarters of data for the one mandatory NHSN measure.
	SUBMISSION METHOD: National Healthcare Safety Network (NHSN) Portal
	DEADLINE: Quarterly Submission Deadline

5. Review your Claims-Based Data

	REQUIREMENT: Facilities are evaluated for their performance on 3 claims-based measures.
	SUBMISSION METHOD: No additional submission is required
	DEADLINE: No Submission Deadline

 

6. Complete the DACA Annually

	REQUIREMENT: Facilities must complete the Data Accuracy and Completeness Acknowledgment (DACA).
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

 

The Data Accuracy and Completeness Acknowledgment (DACA) is a requirement for facilities participating in the IPFQR program. The DACA is a method of electronically attesting that the data they submitted to the program is accurate and complete to the best of their knowledge. You can attest anytime between July 1 - August 15, 2025. Facilities may complete the DACA within the Hospital Quality Reporting (HQR) System.

7. Plan Ahead for the 2025 IPFQR Reporting Year Reporting Requirements

As we mentioned at the top, this year introduces some big changes to the IPFQR program. Per the final rule, CMS has promised two new health equity measures in 2025: SDOH-1 and SDOH-2. We recommend that you take full advantage of this voluntary reporting year in 2024. The more voluntary reporting you do, the better your mandatory reporting rates will be. 

	VOLUNTARY: Facilities are evaluated for their performance on 3 claims-based measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

 

Voluntary Measures	Reporting Period	Submission Period	Data Source	Publicly Reported?
Screening for Social Drivers of Health	CY 2024	July 1 – Aug 15, 2025	Medical Record	Yes
Screen Positive Rate for Social Drivers of Health	CY 2024	July 1 – Aug 15, 2025	Medical Record	Yes

Data Collection Considerations

Hospitals may use a self-selected screening tool to implement these measures. CMS points to AHC Health-Related Social Needs Screening Tool which outlines the questions you could put on a form for patients to answer. This is recommended, not required.

CMS also acknowledges that this data could come from multiple sources: administrative claims data, electronic clinical data, standardized patient assessments, or patient-reported data and surveys. For more guidance, be sure to read our Intro to CMS’s SDOH Measures guide.

Data Submission Methods

Data submission for the IPFQR Program involves several methods, depending on the type of data:

1. Chart-Abstracted Measures: Facilities must meticulously review and extract data from medical records for the current care episode and submit this data to CMS. If you are a Medisolv client, we will submit your chart-abstracted measure performance to CMS on your behalf.
2. Claims-Based Measures: CMS utilizes Medicare enrollment data along with Part A and Part B claims to calculate performance. Facilities do not need to submit additional data for these measures as CMS uses the information provided on the claim.
3. Public Health Registry Measures: Data for measures like the COVID-19 Vaccination Coverage Among Healthcare Personnel must be submitted to the CDC’s National Healthcare Safety Network (NHSN).

 

Get 1:1 Help With Your IPFQR Requirements

If you’re still feeling overwhelmed by your IPFQR requirements, Medisolv is just one call away. We work with leading hospitals and health systems across the country just like yours to organize, update, simplify, and streamline their IPFQR program reporting and processes. Plus, our Medisolv Quality Reporting and Management software platform makes it dramatically easier to meet all your regulatory requirements, maximize your reimbursements, and improve patient care every day.

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More IPFQR Resources

• • IPFQR Program Website
    QualityReportingCenter.com ->Inpatient -> Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program
  • IPFQR Program Webinars
    Select the Webinars link from the top menu on the IPFQR Program landing page
  • IPFQR Program Listserve
    The IPFQR Notify: Inpatient Psychiatric Facility Quality Reporting IPFQR Program Notifications list is available for signup on QualityNet.
  • IPFQR Program Questions & Answers
    Search knowledge articles for answers by keywords or phrases on the CMS Quality, Question & Answer Tool.
  • Phone Support: (866) 800-8765
  • Email Support: QnetSupport@cms.hhs.gov