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IRF Quality Indicator Reporting – Mystery Solved

Written by: Darlene D'Altorio-Jones (1959-2015) on Monday, September 22, 2014 Posted in: Inpatient Rehab

In August of 2012, Mediware posted a blog to help facilities accurately register their unit/facility at the National Health Safety Network (NHSN). The instructions provided within a 14 page handout by NHSN specifically guide IRF facilities and units to accurately register IRF beds and to align those beds with their CMS Certification Number (CCN). When your IRF/U has an R or T as the third digit, it symbolizes to NHSN that you will be reporting as a LOCATION within the acute care facility for which you work. If the CCN on the other hand has the last 4 digits between 3025 and 3099, those entities would sign up as a separate facility at NHSN.

Because facilities/units will suffer a reduction to the base rate of 2 percent when not reporting accurately through NHSN/CDC, it is imperative that the quality liaisons are aware and appropriately designate your operations with the unique ID to get credit for reporting your indicators.

We bring this topic to the forefront once again because of the questions that were asked following our 2015 IRF Final Rule Webinar in August. Persons still appeared confused as to how to register their units accurately with NHSN and how to determine the denominator when reporting specific to the IRF unit. We were fortunate that one of the facilities listening to the call got clarification from Amy Webb, MPH, CHES, Public Health Analyst and Contractor for the NHSN for the Division of Healthcare Quality Promotion (DHQP).

Amy validated in an email to that facility that further guidance would be provided specific to the IRF very shortly. Most essential was that if the facility was a unit within a hospital (having the third digit an R or T in the CCN number), the CCN must be associated with the locations mapped at NHSN for each unit. Those mapped locations are called ‘rehab wards’ within the acute care facility.

As long as the locations are associated with the CCN for your IRF, that automatically NHSN transfers that information in aggregate (all IRF units together), to the CDC for CMS reporting. In that email, Amy reported that denominator reporting is slightly different for IRF’s. Denominators for EACH of the IRF units (if you have more than one), are all reported independent of that unit by location. Because those units are affiliated with ONE CCN or unique IRF ID, NHSN combines the data and sends that to CMS separately as required for IRF. Acute care data from the non-IRF units are not comingled for reporting to CMS.

We hope these links and clarifications will help you to guide your quality liaison so that you too will not get a 2 percent base rate penalty in an upcoming year. Be certain you follow the specific guidelines at NHSN for registering appropriately, assigning your CCN to those unit/s. When done correctly and reported timely, you will be certain to receive full compensation for the care you provide to Medicare beneficiaries.

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