2025 IPFQR 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 2025 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 2025 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) 2027. 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 2025 IPFQR Program introduces a few changes that impact the way data is reported, including the adoption of a new measure and the option to voluntarily report the new PIX Survey measure.

NEW Mandatory Measures

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

NEW Voluntary Measures (Required in CY 2026)

• Psychiatric Inpatient Experience (PIX) survey

2025 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
• Submit two Process 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 PIX survey measure
  
  

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 Two Process Measures Annually

	REQUIREMENT: Facilities must attest to the two process measures.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

5. 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

6. Review your Claims-Based Data

	REQUIREMENT: Facilities are evaluated for their performance on 4 claims-based measures.
	SUBMISSION METHOD: No additional submission is required
	DEADLINE: No Submission Deadline

7. 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, 2026. Facilities may complete the DACA within the Hospital Quality Reporting (HQR) System.

 

8. Plan Ahead for the 2026 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 rolled out a new survey measure in 2026: Psychiatric Inpatient Experience (PIX) survey. We recommend that you take full advantage of this voluntary reporting year in 2025. The more voluntary reporting you do, the better your mandatory reporting rates will be. 

	VOLUNTARY: Facilities may administer and submit the PIX survey.
	SUBMISSION METHOD: Hospital Quality Reporting (HQR) System
	DEADLINE: Annual Submission Deadline

PIX Survey Measure	Measurement Period	Submission Deadline
Psychiatric Inpatient Experience (PIX) Survey (Voluntary)	January 1 – December 31, 2025	August 15, 2026

The Psychiatric Inpatient Experience (PIX) survey is a publicly available, psychometrically validated survey designed specifically for the Inpatient Psychiatric Facility (IPF) setting. PFS facilities must deliver the 23-question survey to clients 24 hours prior to discharge and report the results to CMS. The survey is split into four domains.

Survey Domains:

• Relationship with Treatment Team
• Nursing Presence
• Treatment Effectiveness
• Healing Environment

Response Scale: Five-point scale (strongly disagree, somewhat disagree, neutral, somewhat agree, strongly agree) or "Does Not Apply”

The measure is calculated as five separate rates (one for each of the four domains and one overall rate). The mean scores are calculated by averaging the numerical values of all responses, excluding omitted or "Does Not Apply" responses.

When this measure becomes mandatory in 2026, it will be publicly reported.  It will be displayed as the average rate for each domain and the overall average rate.

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