CMS-10036_IRF-PAI_Revisions Crosswalk

Revisions Crosswalk (Form CMS-10036)

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	All	Across face of pages	Add watermark indicating this is a draft revision	See change in Actions to be Performed column	A draft watermark will stop any user from confusing this revision with the current application for public use.
	Current page 3	Quality Indicators “Respiratory Status,” “Pain,” “Pressure Ulcers,” and “Safety.”	Delete sections: “Respiratory Status,” “Pain,” “Pressure Ulcers,” and “Safety.”	See change in Actions to be Performed column	Voluntary quality indicators section to be replaced by mandatory quality reporting measure to implement Section 1886(j)(7) of the Social Security Act added by section 3004 of the Patient Protection and Affordable Care Act.
	Current Page 3	Quality Indicators “Pressure Ulcers”	Add new Pressure Ulcers section	Pressure Ulcers Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage. 48A. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers ________ ________ Admission Discharge 48B. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stage 3 pressure ulcers ________ ________ Admission Discharge 48C. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers ________ ________ Admission Discharge Worsening in Pressure Ulcer Status Since Admission Indicate the number of current pressure ulcers that were not present or were at a lesser stage at admission. If no current pressure ulcer at a given stage, enter 0. 49A. Stage 2. Enter Number: _____________ 49B. Stage 3. Enter Number: _____________ 49C. Stage 4. Enter Number: _____________ Healed Pressure Ulcers. 50A. Were pressure ulcers present on admission? _________ (0 – No; 1 – Yes) Indicate the number of pressure ulcers that were noted on admission that have completely closed (resurfaced with epithelium). If no healed pressure ulcer at a given stage since admission, enter 0. (Code only if item 50A is 1 – yes) 50B. Stage 2 Enter Number _____________ 50C. Stage 3 Enter Number _____________ 50D. Stage 4 Enter Number _____________	“Pressure Ulcers” section revised to meet new requirements to implement quality reporting program.

1 of 2