WIXLIB

Variable NameVariable Type DescriptionMeasure CodeCharacterThe measure code consists of the CMSID (prefix) and the variable name (suffix)for the corresponding measure score.Example I 001 01 ADJ RATEPrefix: I 001 01Suffix: ADJ RATEScoreCharacterFootnoteNumericSee Table 8 for a complete listing of providerdata measure codes.The measure score for thecorresponding measure code1 The number of cases/patient stays is toosmall to report.2 Data not available for this reportingperiod.3 Results are based on a shorter time periodthan required.4 Data suppressed by CMS for one ormore quarters.5 Data not submitted for this reportingperiod.6 The lower limit of the confidence intervalcannot be calculated if the number ofobserved infections equals zero.7 Results cannot be calculated for thisreporting period.8 This inpatient rehabilitation facility isn'trequired to submit quality data to Medicarebecause it’s paid under a Medicare waiverprogram.See Table 9 for more information on howeach footnote is used.Start DateDateEnd DateDateIRF QRP Data Dictionary, updated: April, 2022The start date of the reporting period for thecorresponding measure code and scoreThe end date of the reporting period for thecorresponding measure code and score10

Table 6: Conditions Data VariablesVariable NameVariable Type DescriptionCMS CertificationNumber (CCN)CharacterThe CCN is used to identify the facilitylistedFacility NameCharacterName of the facilityAddress Line 1Address Line 2CharacterCharacterThe first line of the address of the facilityThe second line of the address of the facilityCityCharacterStateCharacterThe name of the city where the facility islocatedThe two-character postal code where thefacility is locatedZIP CodeNumericThe five-digit postal ZIP code where thefacility is locatedCounty NameCharacterPhone NumberCharacterThe name of the county where thefacility is locatedThe ten-digit telephone number of thefacility. The format is (xxx) yyy-zzzz.IRF QRP Data Dictionary, updated: April, 202211

Variable NameVariable Type DescriptionCMS RegionNumericThe CMS region where the facility islocated. Below is a key to the location ofthe regional offices and the states coveredby each CMS region:1 Boston:Connecticut, Maine, Massachusetts,New Hampshire, Rhode Island,Vermont2 New York:New Jersey, New York, Puerto Rico, VirginIslands3 Philadelphia:Delaware, District of Columbia,Maryland, Pennsylvania, Virginia,West Virginia4 Atlanta:Alabama, Florida, Georgia, Kentucky,Mississippi, North Carolina, SouthCarolina, Tennessee5 Chicago:Illinois, Indiana, Michigan, Minnesota,Ohio, Wisconsin6 Dallas:Arkansas, Louisiana, New Mexico,Oklahoma, Texas7 Kansas City:Iowa, Kansas, Missouri, Nebraska8 Denver:Colorado, Montana, North Dakota,South Dakota, Utah, Wyoming9 San Francisco:Arizona, California, Hawaii, Nevada,Pacific Territories10 Seattle:Alaska, Idaho, Oregon, WashingtonIRF QRP Data Dictionary, updated: April, 202212

Variable NameVariable Type DescriptionConditionCharacterThe medical conditions treated in the facility. Stroke Nervous system disorder (excludingstroke) Brain disease or condition (nontraumatic) Brain injury (traumatic) Spinal cord disease or condition (nontraumatic) Spinal cord injury (traumatic) Hip or femur fracture Hip or knee replacement, amputation orother bone or joint conditions All other conditionsCountCharacterThe count of the correspondingmedical condition for that facility.FootnoteNumericNote: Medical conditions withcounts of less than 11 are labeled as“less than 11” to protect patientconfidentiality.Indicates the relevant footnote.1 Number of cases is too small to report.2 Data not available for this reportingperiod.IRF QRP Data Dictionary, updated: April, 202213

Table 7: National Data Measure CodesI 006 01: Catheter-associated urinary tract infections (CAUTI)National VariablesI 006 01 SIRDescriptionCatheter-associated urinary tract infections (CAUTI) innation; Standardized infection ratio (SIR)I 008 02: Percentage of patients whose functional abilities were assessed andfunctional goals were included in their treatment planNational VariablesI 008 02 OBS RATEDescriptionNational rateI 009 04: Change in patients' ability to care for themselvesNational VariablesI 009 04 OBS RATEDescriptionNational rateI 010 04: Change in patients' ability to move aroundNational VariablesI 010 04 OBS RATEDescriptionNational rateI 011 04: Percentage of patients who are at or above an expected ability tocare for themselves at dischargeNational VariablesI 011 04 OBS RATEDescriptionNational rateI 012 04: Percentage of patients who are at or above an expected ability tomove around at dischargeNational VariablesI 012 04 OBS RATEDescriptionNational rateI 013 01: Percentage of IRF patients who experience one or more falls withmajor injury during their IRF stayNational VariablesI 013 01 OBS RATEDescriptionNational rateI 015 01: Clostridium difficile Infection (CDI)National VariablesI 015 01 SIRDescriptionClostridium difficile Infection (CDI) in nationI 016 01: Influenza vaccination coverage among healthcare personnelNational VariablesI 016 01 OBS RATEDescriptionNational rate of flu vaccinationIRF QRP Data Dictionary, updated: April, 202214

I 017 01: Rate of potentially preventable hospital readmissions 30 days afterdischarge from an IRFNational VariablesDescriptionI 017 01 PPR PD N NO DIFF NATNumber of IRFs in the nation that performed nodifferent than the national rateI 017 01 PPR PD N TOO SMALLNumber of IRFs too small to reportI 017 01 PPR PD N WORSE NATNumber of IRFs in the nation that performedworse than the national rateI 017 01 PPR PD OBSNational unadjusted average potentially preventablereadmission rateI 017 01 PPR PD N BETTER NATNumber of IRFs in the nation that performedbetter than the national rateI 018 01: Rate of potentially preventable hospital readmissions during theIRF stayNational VariablesI 018 01 PPR WI N BETTER NATI 018 01 PPR WI N NO DIFF NATI 018 01 PPR WI N TOO SMALLDescriptionNumber of IRFs in the nation that performedbetter than the national rateNumber of IRFs in the nation that performed nodifferent than the national rateNumber of IRFs too small to reportI 018 01 PPR WI N WORSE NATNumber of IRFs in the nation that performedworse than the national rateI 018 01 PPR WI OBSNational unadjusted average potentially preventablereadmission rateI 019 02: Rate of successful return to home or community from an IRFNational VariablesI 019 02 DTC N BETTER NATI 019 02 DTC N NO DIFF NATI 019 02 DTC N TOO SMALLI 019 02 DTC N WORSE NATI 019 02 DTC OBS RATEDescriptionNumber of IRFs in the nation that performed betterthan the national rateNumber of IRFs in the nation that performed nodifferent than the national rateNumber of IRFs too small to reportNumber of IRFs that performed worse than thenational rateNational observed discharge to community rateI 020 01: Medicare Spending Per Beneficiary (MSPB) for patients in IRFsNational VariablesDescriptionI 020 01 MSPB SCOREMSPB score (national)IRF QRP Data Dictionary, updated: April, 202215

I 021 01: Percentage of patients whose medications were reviewed and whoreceived follow-up care when medication issues were identifiedNational VariablesDescriptionI 021 01 OBS RATENational rateI 022 01: Percentage of patients with pressure ulcers/pressure injuries thatare new or worsenedNational VariablesDescriptionI 022 01 OBS RATENational rateIRF QRP Data Dictionary, updated: April, 202216

Table 8: Provider Data Measure CodesI 006 01: Catheter-associated urinary tract infections (CAUTI)Provider VariablesDescriptionI 006 01 CI UPPERI 006 01 COMP PERFI 006 01 DOPC DAYSI 006 01 ELIGCASESI 006 01 NUMERATORI 006 01 SIRSIR 95% confidence interval - upper limitComparative performance categoryCatheter daysPredicted number of infections (B)Number of infections reported (A)SIR (A/B)I 006 01 CI LOWERStandardized infection ratio (SIR) 95%confidence interval - lower limitI 008 02: Percentage of patients whose functional abilities were assessed andfunctional goals were included in their treatment planProvider VariablesDescriptionI 008 02 DENOMINATORDenominatorI 008 02 OBS RATEFacility rateI 008 02 NUMERATORNumeratorI 009 04: Change in patients' ability to care for themselvesProvider VariablesDescriptionI 009 04 DENOMINATORDenominatorI 009 04 OBS CHG SFCR SCOREAverage observed change scoreI 009 04 ADJ CHG SFCR SCOREAverage risk-adjusted change scoreI 010 04: Change in patients' ability to move aroundProvider VariablesDescriptionI 010 04 ADJ CHG MOBL SCORE Average risk-adjusted change scoreDenominatorI 010 04 DENOMINATORI 010 04 OBS CHG MOBL SCORE Average observed change scoreI 011 04: Percentage of patients who are at or above an expected ability tocare for themselves at dischargeProvider VariablesDescriptionI 011 04 DENOMINATORDenominatorI 011 04 OBS RATEFacility rateI 011 04 NUMERATORNumeratorIRF QRP Data Dictionary, updated: April, 202217

I 012 04: Percentage of patients who are at or above an expected ability tomove around at dischargeProvider VariablesDescriptionI 012 04 DENOMINATORDenominatorI 012 04 OBS RATEFacility rateI 012 04 NUMERATORNumeratorI 013 01: Percentage of IRF patients who experience one or more falls withmajor injury during their IRF stayProvider VariablesI 013 01 NUMERATORI 013 01 DENOMINATORI 013 01 OBS RATEDescriptionNumeratorDenominatorFacility rateI 015 01: Clostridium difficile Infection (CDI)Provider VariablesDescriptionI 015 01 CI UPPERSIR 95% confidence interval - upper limitI 015 01 COMP PERFComparative performance categoryI 015 01 DOPC DAYSI 015 01 ELIGCASESI 015 01 NUMERATORI 015 01 SIRPatient daysPredicted number of infections (B)Number of infections reported (A)SIR (A/B)I 015 01 CI LOWERStandardized infection ratio (SIR) 95%confidence interval - lower limitI 016 01: Influenza vaccination coverage among healthcare personnelProvider VariablesDescriptionI 016 01 DENOMINATORNumber of health care workersI 016 01 OBS RATERate of flu vaccinationI 016 01 NUMERATORNumber of health care workers vaccinatedIRF QRP Data Dictionary, updated: April, 202218

I 017 01: Rate of potentially preventable hospital readmissions 30 days afterdischarge from an IRFProvider VariablesDescriptionI 017 01 PPR PD VOLUMENumber of eligible staysI 017 01 PPR PD OBSUnadjusted potentially preventable readmission rateI 017 01 PPR PD RSRRRisk-standardized potentially preventablereadmission Rate (RSRR)I 017 01 PPR PD RSRR 2 5Lower limit of the 95% confidence interval onthe RSRRI 017 01 PPR PD RSRR 97 5Upper limit of the 95% confidence interval on theRSRRI 017 01 PPR PD COMP PERFComparative performance categoryI 017 01 PPR PD OBS READMNumber of potentially preventablereadmissions following dischargeI 018 01: Rate of potentially preventable hospital readmissions during theIRF stayProvider VariablesDescriptionI 018 01 PPR WI VOLUMENumber of potentially preventablereadmissionsNumber of eligible staysI 018 01 PPR WI OBSUnadjusted potentially preventable readmission rateI 018 01 PPR WI OBS READMI 018 01 PPR WI RSRRI 018 01 PPR WI RSRR 2 5I 018 01 PPR WI RSRR 97 5I 018 01 PPR WI COMP PERFRisk-standardized potentially preventablereadmission Rate (RSRR)Lower limit of the 95% confidence interval onthe RSRRUpper limit of the 95% confidence interval onthe RSRRComparative performance categoryIRF QRP Data Dictionary, updated: April, 202219

I 019 02: Rate of successful return to home or community from an IRFProvider VariablesDescriptionI 019 02 DTC VOLUMENumber of eligible staysI 019 02 DTC OBS RATEObserved discharge to community rateI 019 02 DTC RS RATERisk-standardized discharge to community rateI 019 02 DTC RS RATE 2 5Lower limit of the 95% confidence interval on therisk-standardized discharge to community rateI 019 02 DTC RS RATE 97 5Upper limit of the 95% confidence interval on therisk-standardized discharge to community rateI 019 02 DTC COMP PERFComparative performance categoryI 019 02 DTC NUMBERObserved number of discharges to community (DTC)I 020 01: Medicare Spending Per Beneficiary (MSPB) for patients in IRFsProvider VariablesDescriptionI 020 01 MSPB SCOREMSPB scoreI 020 01 MSPB NUMBNumber of eligible episodesI 021 01: Percentage of patients whose medications were reviewed and whoreceived follow-up care when medication issues were identifiedProvider VariablesDescriptionI 021 01 DENOMINATORDenominatorI 021 01 OBS RATEFacility rateI 021 01 NUMERATORNumeratorI 022 01: Percentage of patients with pressure ulcers/pressure injuries thatare new or worsenedProvider VariablesDescriptionI 022 01 DENOMINATORDenominatorI 022 01 OBS RATEFacility observed rateI 022 01 ADJ RATEFacility risk-adjusted rateI 022 01 NUMERATORNumeratorIRF QRP Data Dictionary, updated: April, 202220

Table 9: Footnote DescriptionsThe footnote numbers below are associated with the Care Compare IRF quality measures:Footnotenumber1Footnote as displayed onCare CompareThe number of cases/patient staysis too small to report.Footnote details IRF QRP Data Dictionary, updated: April, 2022Minimum denominator to publiclyreport for assessment-basedmeasures and MSPB claims-basedmeasure is 20 (denominator isbetween 1-19), and/orMinimum denominator to publiclyreport for the PPR and DTC claimsbased measures is 25 (denominatoris between 1-24), and/orResults that were based on less thanthe maximum possible time periodcausing the provider to not meet theminimum denominator threshold21

Footnotenumber2Footnote as displayed onCare CompareData not available for thisreporting period.Footnote details 3Results are based on a shortertime period than required. IRF QRP Data Dictionary, updated: April, 2022Provider has been open for less than6 months, and/orMinimum denominator to publiclyreport for assessment-based andclaims-based measures was not met(denominator is 0 because ofmeasure exclusion), and/orThere were zero device days orprocedures (CDC NHSN CAUTIand CDI measures only), and/orMinimum denominator to publiclyreport for assessment-based andclaims-based measures was not metbecause there was less than themaximum possible time period usedto collect data for the measure(denominator is 0 because ofmeasure exclusion)Results were based on data reportedfrom less than the maximumpossible time period used to collectdata for the measure, and/orResults that were based on less thanthe maximum possible time periodcausing the provider to not meet theminimum denominator threshold,and/orMinimum denominator to publiclyreport for assessment-based andclaims-based measures was not metbecause there was less than themaximum possible time period usedto collect data for the measure(denominator is 0 because ofmeasure exclusion)22

Footnote as displayed onCare CompareData suppressed by CMS forone or more quarters.Footnote details5Data not submitted for thisreporting period. There was no data (assessment, CDC,claims) to submit for this measurebecause there were no patientsadmitted and discharged from thefacility6The lower limit of the confidenceinterval cannot be calculated if thenumber of observed infectionsequals zero. Applies to CDC/NHSN measuresCDI and CAUTI onlyLower limit of the confidence intervalcannot be calculated because thenumber of infections was zero, and/orLower limit of the confidence intervalcannot be calculated because thenumber of infections was zero andpredicted number of infections wasless than 1 therefore SIR is maskedFootnotenumber4 7Results cannot be calculated forthis reporting period. 8This inpatient rehabilitationfacility isn't required to submitquality data to Medicare becauseit’s paid under a Medicare waiverprogram.IRF QRP Data Dictionary, updated: April, 2022 Data suppressed by CMS for one ormore quarters (provider-specific), orData suppressed by CMS for one ormore quarters (all providers)Applies to CDC/NHSN measuresCDI and CAUTI onlyLower limit of the confidence intervalcannot be calculated because thenumber of infections was zero andpredicted number of infections wasless than 1 therefore SIR is masked,and/orPredicted number of infections wasless than 1 therefore SIR is maskedFacility is not required to submitquality data to Medicare because it ispaid under a Medicare waiverprogram23

Appendix A: Care Compare December 2021 – December 2022 Anticipated IRF Refreshes and Data Collection TimeframesThis table provides the data collection timeframes for IRF quality measures displayed on the Care Compare website. The first column displays theplain-language measure name used on the Care Compare website, the second column displays the full technical measure name, the third columndisplays the reporting cycle which describes the collection period and refresh frequency, and the last columns contain the timeframe for eachquarterly Care Compare website refresh. Periods of performance are subject to change.Care CompareMeasure NamePercentage ofpatients withpressureulcers/pressureinjuries that are newor worsenedPercentage of IRFpatients whoexperience one ormore falls withmajor injury duringtheir IRF stayChange in patients'ability to care forthemselvesChange in patients'ability to movearoundPercentage ofpatients who are ator above anexpected ability tocare for themselvesat dischargeTechnical Measure Name(NQF Number [if Applicable],CMS Measure ID)Changes in Skin IntegrityPost-Acute Care: PressureUlcer/Injury (CMS ID:I022.01)Data CollectionPeriods and ReportingFrequency 1Collection period: Fourrolling quarters (12months).Refresh

IRF Inpatient rehabilitation facility IRF-PAI Inpatient Rehabilitation Facility Patient Assessment Instrument MSPB Medicare spending per beneficiary NHSN National Healthcare Safety Network NQF National Quality Forum PAC Post-acute care QRP Quality Reporting Program SIR Standardized infection ratio . ZIP Code Zone Improvement Plan (ZIP) Code