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pdfDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
PRA Disclosure Statement
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collection is 0938-0842. The time required to complete this information collection is estimated to average 50.5
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
Identification Information*
1.
Payer Information*
20. Payment Source
(02 - Medicare Fee For Service; 51- Medicare-Medicare Advantage;
99 - Not Listed)
Facility Information
A. Facility Name
______________________________________________________________
A. Primary Source
_________
______________________________________________________________
B. Secondary Source
_________
______________________________________________________________
Medical Information*
______________________________________________________________
______________________________________________________________
21. Impairment Group
________
Admission
B. Facility Medicare Provider Number _________________________
2.
Patient Medicare Number ____________________________________
3.
Patient Medicaid Number ____________________________________
4.
Patient First Name __________________________________________
5A. Patient Last Name __________________________________________
5B. Patient Identification Number _________________________________
6.
Birth Date
7.
Social Security Number _____________________________________
8.
Gender (1 - Male; 2 - Female) ________________________________
9.
Race/Ethnicity (Check all that apply)
____/____/_______
MM / DD / YYYY
________
Discharge
Condition requiring admission to rehabilitation; code according to Appendix
A.
22. Etiologic Diagnosis
_________
(Use an ICD 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
24. Comorbid Conditions
Use ICD codes to enter comorbid medical conditions
A.
J.
S.
B.
K.
T.
C.
L.
U.
V.
American Indian or Alaska Native
A. ________
Asian
B. ________
D.
M.
Black or African American
C. ________
E.
N.
W.
F.
O.
X.
G.
P.
Y.
H.
Q.
I.
R.
Hispanic or Latino
D. ________
Native Hawaiian or Other Pacific Islander
E. ________
White
F. ________
10. Marital Status
(1 - Never Married; 2 - Married; 3 - Widowed;
4 - Separated; 5 - Divorced)
_______________
11. Zip Code of Patient's Pre-Hospital Residence
________________
12. Admission Date
____/____/_______
MM / DD / YYYY
13. Assessment Reference Date
____/____/_____
MM / DD / YYYY
25. DELETED
14. Admission Class
(1 - Initial Rehab; 2 - Evaluation; 3 - Readmission;
4 - Unplanned Discharge; 5 - Continuing Rehabilitation)
26. DELETED
Height and Weight
(While measuring if the number is X.1-X.4 round down, X.5 or greater round
up)
25A. Height on admission (in inches) _____________________________
26A. Weight on admission (in pounds) ____________________________
Measure weight consistently, according to standard facility practice (e.g., in
a.m. after voiding, with shoes off, etc.)
15A. Admit From
27.
(01- Home (private home/apt., board/care, assisted living, group home,
transitional living); 02- Short-term General Hospital; 03 - Skilled Nursing
Facility (SNF); 04 - Intermediate care; 06 - Home under care of organized
home health service organization; 50 - Hospice (home);
51 - Hospice (institutional facility); 61 - Swing bed; 62 - Another Inpatient
Rehabilitation Facility; 63 - Long-Term Care Hospital (LTCH);
64 - Medicaid Nursing Facility; 65 - Inpatient Psychiatric Facility;
66 - Critical Access Hospital; 99 - Not Listed)
16A. Pre-hospital Living Setting
Use codes from 15A. Admit From
________________
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. DELETED
17. Pre-hospital Living With
_______________
(Code only if item 16A is 01- Home: Code using 01 - Alone;
02 - Family/Relatives; 03 - Friends; 04 - Attendant; 05 - Other)
18. DELETED
19. DELETED
Version 1.2
Effective October 1, 2014
Page 1 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
39. FIMTM Instrument*
Function Modifiers*
Complete the following specific functional items prior to scoring the
FIMTM Instrument:
29. Bladder Level of Assistance
(Score using FIM Levels 1 - 7)
30. Bladder Frequency of Accidents
(Score as below)
31.
32.
Admission
Discharge
A.
Eating
B.
Grooming
C.
Bathing
D.
Dressing - Upper
E.
Dressing - Lower
F.
Toileting
7 - No accidents
6 - No accidents; uses device such as a catheter
5 - One accident in the past 7 days
4 - Two accidents in the past 7 days
3 - Three accidents in the past 7 days
2 - Four accidents in the past 7 days
1 - Five or more accidents in the past 7 days
SPHINCTER CONTROL
Enter in Item 39G (Bladder) the lower (more dependent) score from Items 29
and 30 above
TRANSFERS
Bowel Level of Assistance
(Score using FIM Levels 1 - 7)
Bowel Frequency of Accidents
(Score as below)
34.
Shower Transfer
Distance Walked
36. Distance Traveled in Wheelchair
38.
Wheelchair
J.
Toilet
K.
Tub, Shower
Discharge
Goal
LOCOMOTION
Admission
Discharge
L.
Walk/Wheelchair
M.
Stairs
COMMUNICATION
N.
Comprehension
O.
Expression
SOCIAL COGNITION
P.
Social Interaction
Admission
Discharge
Q.
Problem Solving
R.
Memory
Admission
Discharge
(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)
* 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.
Version 1.2
Effective October 1, 2014
Bowel
Bed, Chair, 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)
37. Walk
H.
I.
(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)
35.
Bladder
Discharge
Enter in Item 39H (Bowel) the lower (more dependent) score of Items 31and 32
above.
Tub Transfer
G.
Admission
7 - No accidents
6 - No accidents; uses device such as a ostomy
5 - One accident in the past 7 days
4 - Two accidents in the past 7 days
3 - Three accidents in the past 7 days
2 - Four accidents in the past 7 days
1 - Five or more accidents in the past 7 days
33.
Admission
SELF-CARE
W - Walk
C - Wheelchair
B - Both
A - Auditory
V - Visual
B - Both
V - Vocal
N - Nonvocal
B - Both
FIM LEVELS
No Helper
7
Complete Independence (Timely, Safely)
6
Modified Independence (Device)
Helper - Modified Dependence
5
Supervision (Subject = 100%)
4
Minimal Assistance (Subject = 75% or more)
3
Moderate Assistance (Subject = 50% or more)
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
Page 2 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
Discharge Information*
40. Discharge Date
____/____/________
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)
A. 1st Interruption Date
B. 1st Return Date
MM / DD / YYYY
nd
C. 2 Interruption Date
MM / DD / YYYY
D. 2nd Return Date
MM / DD / YYYY
E. 3rd Interruption Date
MM / DD / YYYY
F. 3rd Return Date
MM / DD / YYYY
MM / DD / YYYY
44C. Was the patient discharged alive?
_____________
(0 - No; 1 - Yes)
44D. Patient’s discharge destination/living setting, using codes below: (answer
only if 44C = 1; if 44C = 0, skip to item 46)
(01- Home (private home/apt., board/care, assisted living, group home,
transitional living); 02- Short-term General Hospital; 03 - Skilled Nursing
Facility (SNF); 04 - Intermediate care; 06 - Home under care of
organized home health service organization; 50 - Hospice (home);
51 - Hospice (institutional facility); 61 - Swing bed; 62 - Another
Inpatient Rehabilitation Facility; 63 - Long-Term Care Hospital (LTCH);
64 - Medicaid Nursing Facility; 65 - Inpatient Psychiatric Facility;
66 - Critical Access Hospital; 99 - Not Listed)
45. Discharge to Living With
_____________
(Code only if item 44C is 1 - Yes and 44D 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 code)
47. Complications during rehabilitation stay
(Use ICD codes to specify up to six conditions that
began with this rehabilitation stay)
A. ____________
B. ____________
C. ____________
D. ____________
E. ____________
F. ____________
* 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.
Version 1.2
Effective October 1, 2014
Page 3 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
Quality Indicators- Admission Assessment
Quality Indicators- Discharge Assessment
Unhealed Pressure Ulcer(s)- Admission
Unhealed Pressure Ulcer(s)- Discharge
M0210. Does this patient have one or more unhealed pressure
ulcer(s) at Stage 1 or higher at Admission?
Enter Code
0. No skip to question I0900 on Admission
Assessment
1. Yes continue to question M0300A on Admission
Assessment
M0210. Does this patient have one or more unhealed
pressure ulcer(s) at Stage 1 or higher on Discharge?
Enter Code
M0300. Current Number of Unhealed Pressure Ulcers
at Each Stage- Admission
M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage- Discharge
M0300A. Stage 1: Intact skin with non-blanchable redness of
M0300A. Stage 1: Intact skin with non-blanchable redness of a
a localized area usually over a bony prominence. Darkly
pigmented skin may not have a visible blanching; in dark skin
tones it may appear with persistent blue or purple hues.
Enter Number
M0300A1. Number of Stage 1 pressure ulcers: enter how
many were noted at the time of admission
localized area usually over a bony prominence. Darkly pigmented
skin may not have a visible blanching; in dark skin tones it may
appear with persistent blue or purple hues.
Enter Number
M0300A1. Enter total number of pressure ulcers currently at Stage
1. If patient has no Stage 1 pressure ulcers at
discharge, skip to Item M0300B1.
Enter Number
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.
Enter Number
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)
M0300B. 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.
Enter Number
0. No skip to question M0900A on Discharge
Assessment
1. Yes continue to question M0300A on Discharge
Assessment
M0300B1. Number of Stage 2 pressure ulcers: enter how
many were noted at the time of admission
Version 1.2
Effective October 1, 2014
M0300B. 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.
Enter Number
M0300B1. Enter total number of pressure ulcers currently at Stage
2. (If patient has no Stage 2 pressure ulcers at
discharge, skip to Item M0300C1.)
Enter Number
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.
Enter Number
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.
Enter Number
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
Page 4 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
Enter Number
Quality Indicators- Admission Assessment, Continued
Quality Indicators-Discharge Assessment, Continued
M0300. Current Number of Unhealed Pressure Ulcers
at Each Stage- Admission, Continued
M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage-Discharge, Continued
M0300C. 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.
M0300C. 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.
M0300C1. Number of Stage 3 pressure ulcers: enter how
many were noted at the time of admission
M0300D. 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.
Enter Number
OMB No. 0938-0842
Enter Number
M0300C1. Enter total number of pressure ulcers currently at Stage
3. (If patient has no Stage 3 pressure ulcers at
discharge, skip to Item M0300D1.
Enter Number
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.
Enter Number
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.
Enter Number
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-removeable device at
admission, initially became stageable at a lesser stage, ,
but then progressed to a Stage 3 by the time of
discharge.
M0300D. 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.
Enter Number
M0300D1. Number of Stage 4 pressure ulcers: enter how
many were noted at the time of admission
Enter Number
Version 1.2
Effective October 1, 2014
M0300D1. Enter total number of pressure ulcers currently at Stage
4. (If patient has no Stage 4 pressure ulcers at
discharge, skip to Item M0300E1.)
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.
Enter Number
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.
Enter Number
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.
Page 5 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
Quality Indicators-Admission Assessment, Continued
Quality Indicators-Discharge Assessment, Continued
M0300E. Unstageable Pressure Ulcers due to nonremovable dressing/device: Known but not stageable due to
M0300E. Unstageable Pressure Ulcers due to a nonremovable dressing or device: pressure ulcers that are known
the presence of a non-removable dressing/device.
Enter Number
M0300E1. Number of unstageable pressure ulcers due to
non-removable dressing/device: enter how many
were noted at the time of admission
but not stageable due to the presence of a non-removable dressing
or device.
Enter Number
M0300E1. Enter total number of pressure ulcers currently
Unstageable due to a Non-removable dressing or
device. (If patient has no pressure ulcers
Unstageable due to Non-Removable Device at
discharge, skip to Item M0300F1.)
Enter Number
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 non-removable dressing or device during the IRF
stay; and (b) remained unstageable due to a nonremovable dressing or device until discharge.
Enter Number
M0300F. Unstageable Pressure Ulcers due to slough or
eschar: pressure ulcers that are known but not stageable due to
M0300F. Unstageable Pressure Ulcers due to slough
and/or eschar: pressure ulcers that are known but not
stageable due to coverage of wound bed by slough and/or eschar.
Enter Number
M0300F1. Number of unstageable pressure ulcers due to
slough and/ or eschar: enter how many were noted
at the time of admission
coverage of wound bed by slough and/or eschar.
Enter Number
Enter Number
Enter Number
M0300F1. Enter total number of pressure ulcers currently
Unstageable due to a Slough and/or Eschar. ( If
patient has no pressure ulcers Unstageable due to
Slough and/or Eschar at discharge, skip to Item
M0300G1.)
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.
M0300G. Unstageable Pressure Ulcers with Suspected
Deep Tissue Injury (DTI) in evolution: suspected deep
M0300G. Unstageable Pressure Ulcers with Suspected
Deep Tissue Injury (DTI) in evolution: suspected deep tissue
tissue injury in evolution.
Enter Number
M0300G1. Number of unstageable pressure ulcers with
Suspected Deep Tissue Injury in evolution: enter
how many were noted at the time of admission
Version 1.2
Effective October 1, 2014
injury in evolution.
Enter Number
M0300G1. Enter total number of unstageable pressure ulcers
with Suspected Deep Tissue Injury. (If patient has
no Unstageable pressure ulcers with Suspected Deep
Tissue Injury at discharge, skip to Item M0900A.)
Enter Number
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.
Page 6 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
Quality Indicators- Admission Assessment, Continued
Quality Indicators-Discharge Assessment, Continued
I0900. Pressure Ulcer Risk Conditions- Admission
M0900. Healed Pressure Ulcers- Discharge
Indicate below if the patient has any of the following pressure
ulcer risk conditions:
(NOTE: You must also document the appropriate ICD codes
for any pressure ulcer risk conditions documented below in Item
24 “Comorbid Conditions” above.)
Enter Number
I0900A. Peripheral Vascular Disease (PVD)
0. No 1. Yes
Enter Number
I0900B. Peripheral Arterial Disease(PAD)
0. No 1. Yes
Enter Number
I2900A. Diabetes Mellitus (DM)
If I2900A = 0, skip I2900B-D
0. No 1. Yes
Enter Number
I2900B. Diabetic Retinopathy
0. No 1. Yes
Enter Number
I2900C. Diabetic Nephropathy
0. No 1. Yes
Enter Number
I2900D. Diabetic Neuropathy
0. No 1. Yes
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.
Enter Number
M0900A. Stage 1
Enter Number
M0900B. Stage 2
Enter Number
M0900C. Stage 3
Enter Number
M0900D. Stage 4
O0250. Influenza Vaccine – Discharge - Refer to current version of
IRF-PAI Training Manual for current influenza vaccination
season and reporting period.
Enter Code
O0250A. Did the patient receive the influenza vaccine in this
facility for this year's influenza vaccination season?
0. No Skip to O0250C, If influenza vaccine not
received, state reason
1. Yes Continue to O0250B, Date influenza vaccine
received
O0250B. Date influenza vaccine received Complete
date and skip to Z0400A, Signature of Persons
Completing the Assessment
MM
Enter Code
DD
YYYY
O0250C. If influenza vaccine not received, state reason:
1. Patient not in this facility during this year's influenza
vaccination season
2. Received outside of this facility
3. Not eligible - medical contraindication
4. Offered and declined
5. Not offered
6. Inability to obtain influenza vaccine due to a declared
shortage.
9. None of the above
Version 1.2
Effective October 1, 2014
Page 7 of 8
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0842
Item Z0400A. Signature of Persons Completing the Assessment*
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or coordinated collection of this
information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid
requirements. I understand that this information is used as a basis for ensuring that patients receive appropriate and quality care, and as a basis for payment from
federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned
on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or
administrative penalties for submitting false information.
Signature
Title
Date Information is Provided
Time
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Version 1.2
Effective October 1, 2014
Page 8 of 8
| File Type | application/pdf |
| File Title | Patient Assessment Instrument for Use in an Inpatient Rehabilitation Facility |
| Subject | Rehabilitation, IRF, Rehab, assessment, IRF-PAI, PAI |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2013-11-06 |
| File Created | 2013-11-05 |