CMS-10036_IRF-PAI_Revisions Crosswalk

CMS-10036_IRF-PAI_Revisions Crosswalk.docx

Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

CMS-10036_IRF-PAI_Revisions Crosswalk

OMB: 0938-0842

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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

Shape1 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.


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