Form CMS-10036 IRF PAI Instrument

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21244-1850.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0842

INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
Identification Information*

Payer Information*

1. Facility Information
A. Facility Name
______________________________________________________
______________________________________________________
______________________________________________________
B. Facility Medicare
Provider Number __________________________________
2. Patient Medicare Number _______________________________
3. Patient Medicaid Number _______________________________
4. Patient First Name ____________________________________
5A. Patient Last Name ___________________________________

20. Payment Source
A. Primary Source

_______

B. Secondary Source

_______

(01 - Blue Cross; 02 - Medicare non-MCO;
03 - Medicaid non-MCO; 04 - Commercial Insurance;
05 - MCO HMO; 06 - Workers' Compensation;
07 - Crippled Children's Services; 08 – Developmental
Disabilities Services; 09 - State Vocational Rehabilitation;
10 - Private Pay; 11 - Employee Courtesy;
12 - Unreimbursed; 13 - CHAMPUS; 14 - Other;
15 - None; 16 – No-Fault Auto Insurance;
51 – Medicare MCO; 52 - Medicaid MCO)
Medical Information*

5B. Patient Identification Number ___________________________
6. Birth Date

_______/______/________
MM / DD / YYYY

7. Social Security Number

__________________________

8. Gender (1 - Male; 2 - Female)

_______

9. Race/Ethnicity (Check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

A. _______
B. _______
C. _______
D. _______
E. _______
F. _______

21. Impairment Group

________
________
Admission
Discharge
Condition requiring admission to rehabilitation; code
according to Appendix A, attached.

22. Etiologic Diagnosis
_______________
(Use an ICD-9-CM code to indicate the etiologic problem
that led to the condition for which the patient is receiving
rehabilitation)
23. Date of Onset of Impairment _______/______/________
MM / DD / YYYY

DRAFT

10. Marital Status
(1 - Never Married; 2 - Married; 3 - Widowed;
4 - Separated; 5 - Divorced)

_______

24. Comorbid Conditions; Use ICD-9-CM codes to enter up to
ten medical conditions
A. _______________ B. _______________
C. _______________ D. _______________
E. _______________ F. _______________

11. Zip Code of Patient's Pre-Hospital Residence ______________

G. _______________ H. _______________

Admission Information*
12. Admission Date

13. Assessment Reference Date

_______/______/________
MM / DD / YYYY
_______/______/________
MM / DD / YYYY

14. Admission Class
_______
(1 - Initial Rehab; 2 - Evaluation; 3 - Readmission;
4 - Unplanned Discharge; 5 - Continuing Rehabilitation)
15. Admit From
_______
(01 - Home; 02 - Board & Care; 03 - Transitional Living;
04 - Intermediate Care; 05 - Skilled Nursing Facility;
06 - Acute Unit of Own Facility; 07 - Acute Unit of Another
Facility; 08 - Chronic Hospital; 09 - Rehabilitation Facility;
10 - Other; 12 - Alternate Level of Care Unit; 13 – Subacute
Setting; 14 - Assisted Living Residence)
16. Pre-Hospital Living Setting
(Use codes from item 15 above)

_______

17. Pre-Hospital Living With
(Code only if item 16 is 01 - Home;
Code using 1 - Alone; 2 - Family/Relatives;
3 - Friends; 4 - Attendant; 5 - Other)

_______

18. Pre-Hospital Vocational Category
(1 - Employed; 2 - Sheltered; 3 - Student;
4 - Homemaker; 5 - Not Working; 6 - Retired for
Age; 7 - Retired for Disability)

_______

19. Pre-Hospital Vocational Effort
(Code only if item 18 is coded 1 - 4; Code using
1 - Full-time; 2 - Part-time; 3 - Adjusted Workload)

_______

I. _______________ J. _______________
Medical Needs
25. Is patient comatose at admission?

_____________
0 - No, 1 - Yes

26. Is patient delirious at admission?

_____________
0 - No, 1 - Yes

27. Swallowing Status

________
Admission

________
Discharge

3 - Regular Food: solids and liquids swallowed safely
without supervision or modified food consistency
2 - Modified Food Consistency/ Supervision: subject
requires modified food consistency and/or needs
supervision for safety
1 - Tube /Parenteral Feeding: tube / parenteral feeding
used wholly or partially as a means of sustenance
28. Clinical signs of dehydration

________
Admission

________
Discharge

(Code 0 – No; 1 – Yes) e.g., evidence of oliguria, dry
skin, orthostatic hypotension, somnolence, agitation
*The FIM data set, measurement scale and impairment codes
incorporated or referenced herein are the property of U B
Foundation Activities, Inc. 1993, 2001 U B Foundation
Activities, Inc. The FIM mark is owned by UBFA, Inc.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0842

INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
39. FIMTM Instrument*

Function Modifiers*
Complete the following specific functional items prior to scoring the
FIMTM Instrument:
ADMISSION

ADMISSION

DISCHARGE

GOAL

SELF-CARE
A. Eating

DISCHARGE
B. Grooming

29. Bladder Level of Assistance
(Score using FIM Levels 1 - 7)

C. Bathing
D. Dressing - Upper

30. Bladder Frequency of Accidents
(Score as below)

E. Dressing - Lower
7
6
5
4
3
2
1

-

No accidents
No accidents; uses device such as a catheter
One accident in the past 7 days
Two accidents in the past 7 days
Three accidents in the past 7 days
Four accidents in the past 7 days
Five or more accidents in the past 7 days

F. Toileting
SPHINCTER CONTROL
G. Bladder
H. Bowel

Enter in Item 39G (Bladder) the lower (more dependent) score from Items
29 and 30 above.
ADMISSION
DISCHARGE

TRANSFERS
I. Bed, Chair, Whlchair
J. Toilet

31. Bowel Level of Assistance
(Score using FIM Levels 1 - 7)

K. Tub, Shower

32. Bowel Frequency of Accidents
(Score as below)
LOCOMOTION

7
6
5
4
3
2
1

-

W - Walk
C - wheelChair
B - Both

DRAFT

No accidents
No accidents; uses device such as an ostomy
One accident in the past 7 days
Two accidents in the past 7 days
Three accidents in the past 7 days
Four accidents in the past 7 days
Five or more accidents in the past 7 days

L. Walk/Wheelchair

M. Stairs

A - Auditory
V - Visual
B - Both

COMMUNICATION

Enter in Item 39H (Bowel) the lower (more dependent) score of Items 31
and 32 above.
ADMISSION
DISCHARGE

N. Comprehension
O. Expression

33. Tub Transfer

V - Vocal
N - Nonvocal
B - Both

34. Shower Transfer
SOCIAL COGNITION
P. Social Interaction
(Score Items 33 and 34 using FIM Levels 1 - 7; use 0 if activity does not
occur) See training manual for scoring of Item 39K (Tub/Shower Transfer)
ADMISSION
DISCHARGE

Q. Problem Solving
R. Memory

35.

Distance Walked

36.

Distance Traveled in Wheelchair

(Code items 35 and 36 using: 3 - 150 feet; 2 - 50 to 149 feet;
1 - Less than 50 feet; 0 – activity does not occur)
ADMISSION

DISCHARGE

37. Walk

FIM LEVELS
No Helper
7 Complete Independence (Timely, Safely)
6 Modified Independence (Device)
Helper - Modified Dependence
5 Supervision (Subject = 100%)

38. Wheelchair

4 Minimal Assistance (Subject = 75% or more)

(Score Items 37 and 38 using FIM Levels 1 - 7; 0 if activity does
not occur) See training manual for scoring of Item 39L (Walk/
Wheelchair)

3 Moderate Assistance (Subject = 50% or more)

*The FIM data set, measurement scale and impairment codes
incorporated or referenced herein are the property of U B
Foundation Activities, Inc. 1993, 2001 U B Foundation
Activities, Inc. The FIM mark is owned by UBFA, Inc.

Helper - Complete Dependence
2 Maximal Assistance (Subject = 25% or more)
1 Total Assistance (Subject less than 25%)
0 Activity does not occur; Use this code only at admission

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0842

INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
Quality Indicators

Discharge Information*
40. Discharge Date

Pressure Ulcers

_______/______/________
MM / DD / YYYY

41. Patient discharged against medical advice?

_______
(0 - No, 1 -Yes)

42. Program Interruption(s)

_______
(0 - No; 1 - Yes)

43. Program Interruption Dates
(Code only if Item 42 is 1 - Yes)

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

A. 1st Interruption Date

B. 1st Return Date

MM / DD / YYYY

MM / DD / YYYY

C. 2nd Interruption Date

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.

D. 2nd Return Date
Number of Stage 3 pressure ulcers ________
Admission

MM / DD / YYYY
E. 3rd Interruption Date

MM / DD / YYYY

________
Discharge

MM / DD / YYYY
F. 3rd Return Date

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.

DRAFT
MM / DD / YYYY

44A. Discharge to Living Setting
_______
(01 - Home; 02 - Board and Care; 03 - Transitional
Living; 04 - Intermediate Care; 05 - Skilled Nursing
Facility; 06 - Acute Unit of Own Facility; 07 - Acute Unit of
Another Facility; 08 - Chronic Hospital; 09 - Rehabilitation
Facility; 10 - Other; 11 - Died; 12 - Alternate Level of Care Unit;
13 - Subacute Setting; 14 - Assisted Living Residence)

44B. Was patient discharged with Home Health Services?
_______
(0 - No; 1 - Yes)
(Code only if Item 44A is 01 - Home, 02 - Board and Care,
03 - Transitional Living, or 14 - Assisted Living Residence)

________
Discharge

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.
45. Discharge to Living With
_______
(Code only if Item 44A is 01 - Home; Code using 1 - Alone;
2 - Family / Relatives; 3 - Friends; 4 - Attendant; 5 - Other
46. Diagnosis for Interruption or Death
(Code using ICD-9-CM code)

__________

47. Complications during rehabilitation stay
(Use ICD-9-CM codes to specify up to six conditions that
began with this rehabilitation stay)
A. _____________

B. ______________

C. _____________

D. ______________

E. _____________

F. ______________

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

_____________

*The FIM data set, measurement scale and impairment codes
incorporated or referenced herein are the property of U B
Foundation Activities, Inc. 1993, 2001 U B Foundation
Activities, Inc. The FIM mark is owned by UBFA, Inc.

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