Frequently Asked Questions for the IPFQR Program
Existing Measures
HBIPS-2:
1. Question: Does the term “transitional hold” count as a restraint?
Answer: A physical restraint is any manual method, physical or mechanical
device, material, or equipment that is used as a restriction to manage a patient’s
behavior or restrict freedom of movement, and is not a standard treatment for the
patient’s condition. A transitional hold would be considered a form of restraint.
HBIPS-4 through -7:
1. Question: The chart notes the patient is not a resident of the United States, has
no benefits, and is not entitled to follow up mental health services. Even though
a next level of care provider referral was made, there is no place to transmit the
care plan. Should “refusal of next care provider” be selected for the first care
plan data element? Or should it be documented “referral made” but “care plan
not transmitted?” Neither one of these options seem accurate.
Answer: Beginning with 1/1/15 discharges, for the data element Patient Referral
to Next Level of Care Provider, allowable value 3 (the medical record contains
documentation that the patient’s residence is not in the USA, and they are
returning to another country after discharge) is the appropriate response and will
exclude the case from the discharge measures. For 2014 discharges, allowable
value 4 (documentation that the patient was not referred to the next level of care
provider) is the correct response.
2. Question: Two separate patients were admitted to the behavioral health unit and
both patients left against medical advice (AMA) before seeing a physician. There
is not a discharge summary regarding either of these visits since the physician
never saw them. Could these cases be considered as elopement since they left
without treatment?
Answer: It is up to the facility to determine, per their policy, whether a patient is
considered to have left against medical advice (AMA) or whether it is considered
an elopement. However, ALL patients leaving AMA should be offered a referral
to a next level of care provider. If the patient refuses, the abstractor should
answer accordingly (allowable value 2 for Patient Referral to Next Level of Care
Provider).
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
HBIPS-6 through -7
1. Question: For patients being readmitted within five days, is the exclusion for
readmission to the psych facility or to anywhere in the facility as a whole?
Answer: It is readmission to the facility as a whole (both inpatient and IPF
patients). Since facilities have up to five days to send the Continuing Care Plan
(CCP) after discharge, those patients readmitted within 5 days after discharge
are excluded. This new denominator exclusion was added to HBIPS-6 and -7
beginning with January 2015 discharges.
2. Question: A hospital has two campuses - the main hospital and the Inpatient
Psychiatric Hospital. If a psychiatric inpatient is transferred to the main campus
ER and gets admitted to inpatient status at the main campus with a new
diagnosis, is value 1 the correct response for the Continuing Care Plan (CCP)
data elements? The Notes for Abstraction state, “If the hospital has an electronic
medical record (EMR) and the next level of care provider has access to the
complete hospital EMR, select allowable value 1.”
Answer: If the hospital has an electronic medical record (EMR) and the next
level of care provider has access to the complete hospital EMR, select allowable
value 1 for the Continuing Care Plan (CCP) data elements if the medical record
contains documentation that the next level of care provider has access to the
EMR.
SUB-1
1. Question: Patient was seen in the ER where she was noted to be "intoxicated,
but no blood alcohol level was drawn until the next day.” Results were negative
and she was admitted to the psychiatric unit. Per the notes for abstraction for
data element Alcohol Use Status, “If patient has a blood alcohol test indicative of
acute intoxication, select value 2." Should value 2 be selected based on the
physician’s assessment of intoxication or does there have to be a blood test?
The patient was not later screened for alcohol use after sober.
Answer: There does not have to be a blood alcohol level drawn for this measure.
The physician documentation did not reference the blood alcohol level and acute
intoxication, so it cannot be used to select allowable value 2. An alcohol use
screen should have been performed within the first three days of admission. If a
screen was not performed, select allowable value 6.
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
SUB-1 (continued)
2. Question: Is the blood alcohol test considered a validated screening tool?
Answer: No. The blood alcohol test does not take the place of a validated
screening tool. However, the result of the test can indicate acute intoxication,
which allows the abstractor to select allowable value 2.
3. Question: If the patient is asked “Do you drink alcohol?” and they answer “No,”
can we use this as our validated tool?
Answer: This would be an example of a prescreening question, which may be
used in order to identify a non-drinker and thus eliminate the patient from further
administration of a validation tool. Choose allowable value 1 for the data element
Alcohol Use Status when provided with a negative response to the prescreening
question. Further screening with a validated screening tool should be done on
those patients who do drink to determine if there is a need for intervention.
4. Question: If the patient arrives in the ER and is screened with an appropriate
tool and then gets admitted to a Behavioral Health Unit (BHU), does the patient
need to be re-screened?
Answer: No, the patient does not need to be re-screened. To meet the intent of
the Alcohol Use Screening measure (SUB-1), the patient needs to be screened
with a validated tool within the first three days of admission.
Assessment of Patient Experience of Care Measure
1. Question: How will this question be asked?
Answer: This is an attestation measure. It assesses whether IPFs administer a
detailed assessment of patient experience of care using a standardized collection
protocol and a structured instrument. If the facility answers “yes,” the name of
the survey administered is to be entered.
2. Question: What is considered a standardized collection protocol to assess
patient experience?
Answer: It means that the administration of the instrument occurs under rules or
guidelines that ensure or promote comparability of individual responses.
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
Use of Electronic Health Record
1. Question: How will this measure be collected?
Answer: The facility will attest to one of three statements that best describes the
facility’s typical use of an EHR system (excluding the billing system) during the
reporting period, and whether the use includes the exchange of interoperable
health information with a health information service provider. The three
statements are as follows:
a. The facility most commonly used paper documents or other forms of
information exchange (for example, email) not involving the transfer of
health information using EHR technology at times of transitions in care.
b. The facility most commonly exchanged health information using noncertified EHR technology (that is, not certified under the ONC HIT
Certification Program) at times of transitions in care.
c. The facility most commonly exchanged health information using certified
EHR technology (certified under the ONC HIT Certification Program) at
times of transitions in care.
The attestation should be based on the hospital’s activities as of December 31 of
the reporting year.
2. Question: What does the attestation ask?
Answer: It asks which of the three statements best describes the facility’s typical
use of an EHR system (excluding the billing system) during the reporting period,
and whether the use includes the exchange of interoperable health information
with a health information service provider.
3. Question: What timeframe is used?
Answer: The attestation should be based on the hospital’s activities as of
December 31 of the reporting year.
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
New Measures for CY 2015
IMM-2
1. Question: When is the reporting period for IMM-2?
Answer: Since this measure covers vaccination during the influenza season,
data collection (data reporting) will occur only during that time, October 1, 2015
through March 31, 2016. Data submission will occur July 1- August 15, 2016.
2. Question: How do we collect the data for IMM-2?
Answer: For the purposes of the IPF Quality Reporting Program, IMM-2 is a
chart abstracted measure and includes only those patients admitted to the IPF.
Facilities will submit data via the QualityNet Portal July 1 – August 15, 2016.
3. Question: How is IMM-2 going to be reported for the IPFs?
Answer: Data collection will start with the 2015 to 2016 influenza season
(October 1, 2015 to March 31, 2016) with submission July 1- August 15, 2016.
Reporting on Hospital Compare will occur in April 2017.
Influenza Vaccination Coverage Among Healthcare Personnel
1. Question: How is this measure reported?
Answer: IPFs will use the CDC National Healthcare Safety Network (NHSN)
infrastructure and protocol to report the measure for the IPFQR program. It will
be necessary to perform set up prior to reporting. Step-by-step instructions are
available at http://www.cdc.gov/nhsn/acute-care-hospital/setup.html . An
operational guidance document to assist with reporting this measure is posted on
the CDC website at http://www.cdc.gov/nhsn/acute-care-hospital/hcpvaccination/index.html.
Follow-Up After Hospitalization for Mental Illness (FUH)
1. Question: How will this measure be calculated?
Answer: CMS will calculate this measure by linking Medicare Fee-For-Service
(FFS) Parts A & B claims data. Details concerning the calculation of the measure
are available in the program manual.
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
Follow-Up After Hospitalization for Mental Illness (FUH) (continued)
2. Question: How is the FUH measure abstracted?
Answer: The FUH measure does not require data abstraction or reporting by the
IPF. CMS will calculate this measure by linking Medicare Fee-For-Service (FFS)
Parts A & B claims data.
TOB-1
1. Question: Where can the TOB specifications be found, since they are not on the
Joint Commission website?
Answer: The TOB specifications are found in the Specifications Manual for
National Hospital Inpatient Quality Measures Discharges 01-01-15 (1Q15)
through 09-30-15 (3Q15) located at:
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%
2FPage%2FQnetTier4&cid=1228773989482 .
2. Question: Will documentation of "smoker" or "smokeless" tobacco use suffice for
type of tobacco product used?
Answer: Yes. The use of "smoker" would equate to cigarette use and
"smokeless tobacco" to the use of smokeless tobacco.
3. Question: Is a specific screening tool recommended or required for the TOB
measures for FY2017 IPFQR?
Answer: There is no recommended or required screening tool for the TOB
measures.
4. Question: Which healthcare providers can complete the screening for tobacco
use and who can provide the initial counseling within the three day window?
Answer: Any healthcare provider can complete the screening for tobacco use
and provide the initial counseling.
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
TOB-2 and -2a
1. Question: What constitutes practical counseling?
Answer: The components of practical counseling require interaction with the
patient to address the following: recognizing dangerous situations, developing
coping skills, and providing basic information about quitting. More information
can be found in the Public Health Service Guideline entitled Counseling Patients
to Quit: http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/counsel.pdf.
2. Question: Will Nicotine gum or patch prescribed as a PRN medication during the
admission qualify as FDA-approved cessation medications offered during
admission?
Answer: Those medications are listed in Table 9.1 FDA-Approved Tobacco
Cessation Medications, so they qualify as appropriate medications. Per the
Notes for Abstraction for data element Tobacco Use Treatment FDA-Approved
Cessation Medication, if the nicotine replacement therapy is ordered PRN and
the patient does not receive any doses during the hospital stay, select allowable
value 2 (the patient refused the FDA-approved tobacco cessation medications
during the hospital stay).
3. Question: Does the patient have to sign the counseling/education/referral forms
to indicate that they received them or can a nurse document in the chart that this
information was provided?
Answer: No. The patient does not need to sign the form as long as the nurse
documents it was provided and interaction occurred.
Cognitive Impairment – Applies to SUB-1 and all TOB measures
1. Question: Must the chart specifically state the words "cognitive impairment,”
“altered mental status,” or “confused” to select "YES"? Can terms such as
“delusional” or “loose associations” be used to determine cognitive impairment?
Answer: There is not an all-inclusive list of terms that can be used to determine
cognitive impairment; however, examples of terms that equate to cognitive
impairment in the data elements can be found on pages 1-27 (SUB-1) and 1-390
(TOB) of the Alphabetical Data Dictionary of the National Hospital Inpatient
Quality Reporting Measures Specifications Manual Release Notes v4.4.
2. Question: Effective January 2015, the data element Cognitive Impairment is no
longer in the alphabetical data dictionary. Cognitive impairment is, however, still
listed as a denominator exclusion for SUB-1. Please explain how we can exclude
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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Frequently Asked Questions for the IPFQR Program
Cognitive Impairment (continued) – Applies to SUB-1 and all TOB measures
cases for cognitive impairment without a data element question and allowable
values to guide abstraction?
Answer: Beginning with January 1, 2015 discharges, a new allowable value has
been added to the Alcohol Use Status data element. The new allowable value is
“7: The patient was not screened for alcohol use during the first three days of
admission because of cognitive impairment.” In 2015, cognitive impairment must
be present the first three days of admission only, not the entire hospitalization.
For the data element Tobacco Use Status, the new allowable value is “6: The
patient was not screened for tobacco use during the first three days of admission
because of cognitive impairment.”
Sampling
1. Question: Does the initial population for the SUB-1, TOB-1, TOB-2, and TOB-2a
measures in the IPFQR program include only inpatient psychiatric patients or all
inpatient discharges?
Answer: The initial population includes only the IPF’s population.
Facility/State/National (FSN) Report
1. Question: How do I get my FSN report?
Answer: The Facility/State/National (FSN) report is located in the QualityNet
Secure Portal under My Reports. Log in to the QualityNet Secure Portal. Choose
Inpatient Psychiatric Quality Reporting Program. Log in to Quality Net using your
User ID, Password and Security Code. To run a Hospital Reporting – Inpatient
Psychiatric Facility, State, and National Report:
 Select “Run Reports” from the “My Reports” drop down menu in the yellow
tool bar near the top of the summary screen.
 Select the “Run Report(s)” tab.
 Select “IPFQR” for Report Program and “Hospital Reporting Feedback –
IPFQR” for Report Category. Select the [VIEW REPORTS] button.
 Select the “Hospital Reporting – Inpatient Psychiatric Facility, State, and
National Report.”
 Enter your desired report parameters. Enter “2014” for Payment Year.
 Select the [Run Report] button.
 Select the “Search Reports” tab.
 Select the new report and open it.
This material was prepared by the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. HHSM-500-2013-13007I, FL-IQR-Ch8-02052015-06
Discharges 01-01-15 (Q1 2015) through 9-30-15 (Q3 2015)
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