CMS certified IPF Locations within Acute Care, Critical Access, Long

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CMS certified IPF Locations within Acute Care, Critical Access, Long-term

Acute Care Hospitals, and free-standing Inpatient Rehab Facilities

Location Mapping

Updated January 2021 to include LTACHs and free-standing IRFs

The NHSN application allows users with inpatient psychiatric facility (IPF) units within acute care, critical access

hospitals, long-term acute care hospitals (LTACHs), and free-standing inpatient rehabilitation facilities (IRFs) to

appropriately designate whether the unit is a separately licensed CMS IPF. This applies only to those units that

have an ‘M’, ‘S’, ‘SA’, ‘SB’, ‘SC’, ‘SD’ or ‘SE’ in the 3rd position of their CMS Certification Number (CCN). All IPFs

with the last four digits of their CCN between 4000-4499 should be enrolled into NHSN as a separate

Psychiatric Hospital. It’s important to note that psychiatric units within a hospital/IRF may have a CCN that is

different from the hospital only by the letter in the 3rd position. Therefore, it is essential to double check the

CCN with the billing/administrative departments at your facility prior to moving forward with location set-up.

The updated functionality within NHSN will allow users to designate specific psychiatric locations within the

hospital as separately licensed CMS units. In addition, users will be able to enter the psychiatric specific CCN,

thus allowing the data to be appropriately sent to CMS to satisfy IPF Quality Reporting Program (QRP)

requirements. Further, once the IPF CCN has been entered into NHSN, any LabID events entered from these

locations will be excluded from the acute care data sent to CMS for the Hospital Inpatient Quality Reporting

Program.

The following instructions will demonstrate two different scenarios that could be applicable to your facility: A)

users without a psychiatric location currently mapped within their NHSN hospital or B) users with a psychiatric

location currently mapped within their NHSN hospital.

Scenario A: Users without psychiatric locations currently mapped within their NHSN hospital

Adding a psychiatric location within NHSN

1. Go to the location manager screen by clicking on ‘Facility’ then ‘Locations’ on the left-hand navigation

bar.

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2. Enter the ‘Your Code’ and ‘Your Label’ values that will help you to identify the new psychiatric location

among the other locations already mapped in your NHSN facility. Each ‘Your Code’ value must be

unique within your NHSN facility. The ‘Your Label’ value can be used more than once.

3. In the CDC Location Description drop down menu, select the appropriate psychiatric designation

(‘Behavioral Health/Psych Ward,’ ‘Adolescent Behavioral Health Ward,’ or ‘Pediatric Behavioral Health

Ward’). (See NHSN Locations and Descriptions Chapter for location definitions:

http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf)

a. Upon selecting the appropriate psychiatric designation, the additional questions will appear as

shown in the screenshot below.

4. If you wish to designate this psychiatric location as a CMS IPF unit you will select ‘Yes’ in response to ‘Is

this location a CMS IPF unit within a hospital?’ If this is not a CMS IPF unit, select ‘No’ and go to Step 6.

5. Next, to enter the IPF’s CCN, click on the blue ‘Edit IPF CCN’ link.

a. On the Edit CCN Records pop up, click the grey Add Row button to add a row for the CCN.

b. Enter the CCN and Effective Date in the appropriate boxes. The Effective Reporting Quarter will

automatically populate after the Effective Date is entered.

i. It is very important to make sure you are correctly entering your CCN.

ii. In order to qualify as a CMS IPF unit within a hospital, the CCN must have an ‘M’, ‘S’,

‘SA’, ‘SB’, ‘SC’, ‘SD’ or ‘SE’ in the 3rd position.

iii. If the CCN does not have an ‘M’, ‘S’, ‘SA’, ‘SB’, ‘SC’, ‘SD’ or ‘SE’ in the 3rd position but

instead has the last four digits between 4000-4499, the IPF must be enrolled as a

separate facility and NOT as a location within the hospital/IRF.

iv. NOTE: The CCN shown in the screenshot below is for example only. Please obtain your

facility specific IPF CCN for entry into this field.

c. Click the ‘Save’ button to save the changes.

d. Click the ‘OK’ button on the Alert pop up.

e. Click the ‘Close’ button to close the Edit CCN Records pop up to return to the Locations page.

(Steps 4 – 5c are illustrated on the below screenshot)

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6. The new location should be listed with ‘Active’ status and an accurate bed size. After completing all the

fields, click ‘Add’ to add the location.

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Scenario B: Users with psychiatric locations currently mapped within their NHSN hospital

Updating an existing psychiatric location

1. Go to the location manager screen by clicking on ‘Facility’ then ‘Locations’ on the left-hand navigation

bar.

2. From the CDC Location Description drop down menu, select ‘Behavioral Health/Psych Ward,’

‘Adolescent Behavioral Health Ward,’ or ‘Pediatric Behavioral Health Ward’ to find the psychiatric

location(s) already mapped within your facility.

3. Leaving all other fields blank, click the grey ‘Find’ button.

a. Scroll down the screen to see the Location table. You should see the psychiatric unit(s) that you

have previously mapped.

4. Click on the underlined blue value in the ‘Your Code’ column as shown in the screenshot below.

a. This will move the information for this location up to the blank fields above the location table.

(Steps 2 – 4 are illustrated on the below screenshot)

5. If you wish to recognize this psychiatric location as a CMS IPF unit, then change the response to ‘Is this

location a CMS IPF unit within a hospital’ from ‘No’ to ‘Yes.’

6. Next, to enter the IPF’s CCN, click on the blue ‘Edit IPF CCN’ link.

a. On the Edit CCN Records pop up, click the grey ‘Add Row’ button to add a row for the CCN.