Form CMS-10036 Voluntary/Mandatory Items

Voluntary/Mandatory Items for IRF-PAI Version 1.2 (Effective October 1, 2014) Quality Indicator Items - IRF Quality Reporting Program

Table 1. Quality Reporting Items on the IRF-PAI Version 1.2 Admission Items

IRF-PAI Item (Admission)	Mandatory or Voluntary1	Rationale for Mandatory Status
25A. Height on admission (in inches)	Mandatory	Required in order to risk adjust the New or Worsened Pressure Ulcer quality measure.
26A. Weight on admission (in pounds)	Mandatory	Required in order to risk adjust the New or Worsened Pressure Ulcer quality measure.
M0210. Unhealed Pressure Ulcer(s) - Admission Does this patient have one or more unhealed pressure ulcer(s) at Stage 1 or higher at Admission?	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
M0300A1. Number of Stage 1 pressure ulcers	Voluntary
M0300B1. Number of Stage 2 pressure ulcers	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
M0300C1. Number of Stage 3 pressure ulcers	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
M0300D1. Number of Stage 4 Pressure Ulcers	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
M0300E1. Number of unstageable pressure ulcers due to non-removable dressing/device	Voluntary
M0300F1. Number of unstagable pressure ulcers due to slough and/or eschar	Voluntary
M0300G1. Number of unstageable pressure ulcers with suspected Deep Tissue Injury (DTI) in evolution	Voluntary
I0900A. Peripheral Vascular Disease (PVD)	Mandatory	Required in order to risk adjust the New or Worsened Pressure Ulcer quality measure.
I0900B. Peripheral Arterial Disease (PAD)	Mandatory	Required in order to risk adjust the New or Worsened Pressure Ulcer quality measure.
I2900A. Diabetes Mellitus (DM)	Mandatory	Required in order to risk adjust the New or Worsened Pressure Ulcer quality measure.
I2900B. Diabetic Retinopathy	Voluntary
I2900C. Diabetic Nephropathy	Voluntary
I2900D. Diabetes Neuropathy	Voluntary

Table 2. Quality Reporting Items on the IRF-PAI Version 1.2 Discharge Item

IRF-PAI Item	Mandatory or Voluntary	Rationale for Mandatory Status
M0210. Unhealed Pressure Ulcer(s) - Discharge Does this patient have one or more unhealed pressure ulcer(s) at Stage 1 or higher on Discharge?	Mandatory	Required in order to calculate the New or Worsened Pressure Ulcer quality measure.
M0300A1. Enter total number of pressure ulcers currently at Stage 1.	Voluntary
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.	Voluntary
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)	Voluntary
M0300B1. Enter total number of pressure ulcers currently at Stage 2.	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
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.	Voluntary
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.	Voluntary
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	Required in order to calculate the New or Worsened Pressure Ulcer quality measure.
M0300C1. Enter total number of pressure ulcers currently at Stage 3.	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
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.	Voluntary
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.	Voluntary
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.	Mandatory	Required in order to calculate the New or Worsened Pressure Ulcer quality measure.
M0300D1. Enter total number of pressure ulcers currently at Stage 4.	Mandatory	Required in order to validate the New or Worsened Pressure Ulcer quality measure.
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.	Voluntary
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.	Voluntary
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.	Mandatory	Required in order to calculate the New or Worsened Pressure Ulcer quality measure.
M0300E1. Enter total number of pressure ulcers currently Unstageable due to a Non-removable dressing or device.	Voluntary
M0300E2. Of these Unstageable pressure ulcers due to a non-removable 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.	Voluntary
M0300E3. Of these Unstageable pressure ulcers due to non-removable dressing or device present at discharge, enter number that were (a) present on admission as a stageable pressure ulcer and became unstageable due to non-removable dressing or device during the IRF stay; and (b) remained unstageable due to a non-removable dressing or device until discharge.	Voluntary
M0300F1. Enter total number of pressure ulcers currently Unstageable due to a Slough and/or Eschar	Voluntary
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.	Voluntary
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.	Voluntary
M0300G1. Enter total number of unstageable pressure ulcers with Suspected Deep Tissue Injury (DTI) in evolution.	Voluntary
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.	Voluntary
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.	Voluntary
O0250A. Did the patient receive the influenza vaccine in this facility for this year’s influenza vaccination season?	Mandatory	Required in order to calculate the Patient Influenza Vaccination quality measure.
O0250B. Date influenza vaccine received	Mandatory	Required in order to validate the Patient Influenza Vaccination quality measure.
O0250C. If influenza vaccine not received, state reason: 1- 9	Mandatory	Required in order to calculate the Patient Influenza Vaccination quality measure.

1 If the facility does not wish to submit information for a voluntary item, a value of an equal sign "=" can be submitted.