2024 IPFQR Reporting Requirements | Medisolv

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

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

3. Attest to One Structural Measure Annually

4. Submit NHSN Measures Quarterly

5. Review your Claims-Based Data

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