Form CMS-10036 Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Ver

Voluntary/Mandatory Items for Proposed DRAFT IRF-PAI Version 1.2 (Proposed DRAFT
Effective October 1, 2014) Assessment Quality Indicator Items- Sect 3004 IRF Quality
Reporting Program
April 10, 2013
Table 1. Quality Reporting Items on the Proposed DRAFT IRF-PAI Version 1.2 Admission Item
Set
IRF-PAI Item (Admission)
25A. Height on admission (in
inches)
26A. Weight on admission (in
pounds)
M0210. Unhealed Pressure
Ulcer(s) - Admission
Does this patient have one or more
unhealed pressure ulcer(s) at Stage
1 or higher at Admission?
M0300A1. Number of Stage 1
pressure ulcers
M0300B1. Number of Stage 2
pressure ulcers
M0300C1. Number of Stage 3
pressure ulcers
M0300D1. Number of Stage 4
Pressure Ulcers
M0300E1. Number of unstageable
pressure ulcers due to nonremovable dressing/device
M0300F1. Number of unstageable
pressure ulcers due to slough
and/or eschar
M0300G1. Number of
unstageable pressure ulcers with
suspected Deep Tissue Injury
(DTI) in evolution
I0900A. Peripheral Vascular
Disease (PVD)
I0900B. Peripheral Arterial Disease
(PAD)
I2900A. Diabetes Mellitus (DM)
I2900B. Diabetic Retinopathy
I2900C. Diabetic Nephropathy
I2900D. Diabetes Neuropathy

Mandatory or
Voluntary
Mandatory
Mandatory
Mandatory

Rationale for Mandatory Status
Required in order to risk adjust the New or
Worsened Pressure Ulcer quality measure.
Required in order to risk adjust the New or
Worsened Pressure Ulcer quality measure.
Required in order to validate the New or
Worsened Pressure Ulcer quality measure.

Voluntary

N/A

Mandatory

Voluntary

Required in order to validate the New or
Worsened Pressure Ulcer quality measure.
Required in order to validate the New or
Worsened Pressure Ulcer quality measure.
Required in order to validate the New or
Worsened Pressure Ulcer quality measure.
N/A

Voluntary

N/A

Voluntary

N/A

Mandatory

Required in order to risk adjust the New or
Worsened Pressure Ulcer quality measure.
Required in order to risk adjust the New or
Worsened Pressure Ulcer quality measure.
Required in order to risk adjust the New or
Worsened Pressure Ulcer quality measure.
N/A
N/A
N/A

Mandatory
Mandatory

Mandatory
Mandatory
Voluntary
Voluntary
Voluntary

Table 2. Quality Reporting Items on the Proposed DRAFT IRF-PAI Version 1.2 Discharge
Assessment Item Set
IRF-PAI Item
M0210. Unhealed Pressure
Ulcer(s) - Discharge
Does this patient have one or more
unhealed pressure ulcer(s) at Stage
1 or higher on Discharge?
M0300A1. Enter total number of
pressure ulcers currently at Stage 1.
M0300A2. Of these Stage 1
pressure ulcers present at discharge,
enter number that were: (a) present
on admission as a Stage 1 and (b)
remained at Stage 1 at discharge.
M0300A3. Of these Stage 1
pressure ulcers, enter the number
that were not present on
admission. (i.e. – New stage 1
pressure ulcers that have developed
during the IRF stay)
M0300B1. Enter total number of
pressure ulcers currently at Stage 2.
M0300B2. Of these Stage 2
pressure ulcers present at discharge,
enter the number that were: (a)
present on admission, and (b)
remained at Stage 2 at discharge.
M0300B3. Of these Stage 2
pressure ulcers present at discharge,
enter the number that were: (a)
present on admission as an
unstageable pressure ulcer due to
the presence of a non-removable
device and (b) when it became
stageable, the pressure ulcer was
staged as a Stage 2, and (c) it
remained at Stage 2 at the time of
discharge.
M0300B4. Of these Stage 2
pressure ulcers present at discharge,
enter the number that were: (a) not
present on admission; or (b) were at
a lesser stage at admission and
worsened to a Stage 2 during the
IRF stay

Mandatory or
Voluntary
Mandatory

Rationale for Mandatory Status
Required in order to calculate the New or
Worsened Pressure Ulcer quality measure.

Voluntary

N/A

Voluntary

N/A

Voluntary

N/A

Mandatory
Voluntary

Required in order to validate the New or
Worsened Pressure Ulcer quality measure.
N/A

Voluntary

N/A

Mandatory

Required in order to calculate the New or
Worsened Pressure Ulcer quality measure.

IRF-PAI Item
M0300C1. Enter total number of
pressure ulcers currently at Stage 3.
M0300C2. Of these Stage 3
pressure ulcers present at discharge,
enter the number that were: (a)
present on admission, and (b)
remained at Stage 3 at discharge.
M0300C3. Of these Stage 3
pressure ulcers present at discharge,
enter the number that were: (a)
present on admission as an
unstageable pressure ulcer, and
(b) when it became stageable, it
was staged as a Stage 3; and (c) it
remained at Stage 3 at the time of
discharge.
M0300C4. Of these Stage 3
pressure ulcers present at discharge,
enter the number that were: (a) not
present on admission; or (b) were at
a lesser stage at admission and
worsened to a Stage 3 during the
IRF stay; or (c) were unstageable
due to a non-removable device at
admission, initially became
stageable at a lesser stage, but then
progressed to a Stage 3 by the time
of discharge.
M0300D1. Enter total number of
pressure ulcers currently at Stage 4.
M0300D2. Of these Stage 4
pressure ulcers present at discharge,
enter number that were: (a) present
on admission at Stage 4, and (b)
remained at Stage 4 at discharge.
M0300D3. Of these Stage 4
pressure ulcers present at discharge,
enter the number that were: (a)
present on admission as an
unstageable pressure ulcer, and (b)
when it became stageable, it was
staged as a Stage 4, and (c) it
remained at Stage 4 at the time of
discharge.

Mandatory or
Voluntary
Mandatory

Rationale for Mandatory Status
Required in order to validate the New or
Worsened Pressure Ulcer quality measure.

Voluntary

N/A

Voluntary

N/A

Mandatory

Required in order to calculate the New or
Worsened Pressure Ulcer quality measure.

Mandatory
Voluntary

Required in order to validate the New or
Worsened Pressure Ulcer quality measure.
N/A

Voluntary

N/A

IRF-PAI Item
M0300D4. Of these Stage 4
pressure ulcers present at discharge,
enter the number that were: (a) not
present on admission; or (b) were at
a lesser stage at admission and
worsened to a Stage 4 by discharge;
or (c) were unstageable on
admission, initially became
stageable at a lesser stage, and then
progressed to a Stage 4 by the time
of discharge.
M0300E1. Enter total number of
pressure ulcers currently
Unstageable due to a Nonremovable dressing or device.
M0300E2. Of these Unstageable
pressure ulcers due to a nonremovable dressing or device
present at discharge, enter number
that were:(a) present on admission
as an unstageable pressure ulcer
due to non-removable dressing or
device; and (b) remained
unstageable due to non-removable
dressing or device until discharge.
M0300E3. Of these Unstageable
pressure ulcers due to nonremovable dressing or device
present at discharge, enter number
that were (a) present on admission
as a stageable pressure ulcer and
became unstageable due to nonremovable dressing or device
during the IRF stay; and (b)
remained unstageable due to a nonremovable dressing or device until
discharge.
M0300F1. Enter total number of
pressure ulcers currently
Unstageable due to a Slough
and/or Eschar

Mandatory or
Voluntary
Mandatory

Rationale for Mandatory Status
Required in order to calculate the New or
Worsened Pressure Ulcer quality measure.

Voluntary

N/A

Voluntary

N/A

Voluntary

N/A

Voluntary

N/A

IRF-PAI Item
M0300F2. Of these Unstageable
pressure ulcers due to slough
and/or eschar present at discharge,
enter number that were: (a) present
on admission as an unstageable
pressure ulcer due to slough and/or
eschar; and (b) remained
unstageable due to slough and/or
eschar until discharge.
M0300F3. Of these Unstageable
pressure ulcers due to slough or
eschar present at discharge, enter
number that were: (a) present on
admission as a stageable pressure
ulcer; and became unstageable due
to slough and/or eschar during the
IRF stay; and (b) remained
unstageable due to slough and/or
eschar until discharge.
M0300G1. Enter total number of
unstageable pressure ulcers with
Suspected Deep Tissue Injury
(DTI) in evolution.
M0300G2. Of these unstageable
pressure ulcers with suspected
DTI present at discharge, enter
number that were:(a) present on
admission as an unstageable
pressure ulcer due to a suspected
deep tissue injury; and (b)
remained unstageable due to a
suspected DTI until discharge.
M0900A-D. Indicate the number of
pressure ulcers that were: (a)
present on Admission: and (b)
have completely closed (resurfaced
with epithelium) upon Discharge.
If there are no healed pressure
ulcers noted at a given stage, enter
0.
O0250A. Did the patient receive
the influenza vaccine in this
facility for this year’s influenza
vaccination season?
O0250B. Date influenza vaccine
received

Mandatory or
Voluntary
Voluntary

N/A

Voluntary

N/A

Voluntary

N/A

Voluntary

N/A

Voluntary

N/A

Mandatory

Required in order to calculate the Patient
Influenza Vaccination quality measure.

Mandatory

Required in order to validate the Patient
Influenza Vaccination quality measure.

Rationale for Mandatory Status

IRF-PAI Item
O0250C. If influenza vaccine not
received, state reason: 1- 9

Mandatory or
Voluntary
Mandatory

Rationale for Mandatory Status
Required in order to calculate the Patient
Influenza Vaccination quality measure.