Appendix B: Change table V1.3 to 1.4

Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

1.

Admission &
Discharge

Version

Version 1.3

Version 1.4

2.

Admission

Section B

N/A – New Section Header

Section B Hearing, Speech, and Vision

3.

Admission

BB0700

N/A – new item

BB0700. Expression of Ideas and Wants (3-day
assessment period)
Expression of Ideas and Wants (consider both verbal and
non-verbal expression and excluding language barriers)
4. Expresses complex messages without difficulty and with
speech that is clear and easy to understand
3. Exhibits some difficulty with expressing needs and ideas
(e.g., some words or finishing thoughts) or speech is not
clear
2. Frequently exhibits difficulty with expressing needs and
ideas
1. Rarely/Never expresses self or speech is very difficult to
understand

New item added to collect data for
function quality measures.

BB0800. Understanding Verbal Content (3-day
assessment period)
Understanding Verbal Content (with hearing aid or device,
if used and excluding language barriers)
4. Understands: Clear comprehension without cues or
repetitions
3. Usually Understands: Understands most conversations,
but misses some part/intent of message. Requires cues at
times to understand
2. Sometimes Understands: Understands only basic
conversations or simple, direct phrases. Frequently
requires cues to understand
1. Rarely/Never Understands

New item added to collect data for
function quality measures.

4.

Admission

BB0800

N/A – new item

Updates to Quality Indicators
section

Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

5.

Admission

Section C

N/A – new section header

Section C Cognitive Patterns

6.

Admission

C0100

N/A – new item

C0100. Should Brief Interview for Mental Status (C0200C0500) be conducted? (3-day assessment period)
Attempt to conduct interview with all patients.
0. No (patient is rarely/never understood)  Skip to
C0900. Memory/Recall Ability
1. Yes  Continue to C0200. Repetition of Three Words

New item added to collect data for
function quality measures.

7.

Admission

C0200

N/A – new item

Brief Interview for Mental Status (BIMS)

New item added to collect data for
function quality measures.

C0200. Repetition of Three Words
Ask patient: “I am going to say three words for you to
remember. Please repeat the words after I have said all
three. The words are: sock, blue and bed. Now tell me the
three words.”
Number of words repeated by patient after first attempt:
3. Three
2. Two
1. One
0. None

Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

After the patient's first attempt say: “I will repeat each of
the three words with a cue and ask you about them later:
sock, something to wear; blue, a color; bed, a piece of
furniture.” You may repeat the words up to two more
times.
(continued)

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July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#
8.

Admission or
Discharge
Assessment
Admission

Item / Text
Affected
C0300A
C0300B
C0300C

IRF-PAI Version 1.3
N/A – new items

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
Brief Interview for Mental Status (BIMS) – Continued
C0300. Temporal Orientation: Year, Month, Day
A. Ask patient: “Please tell me what year it is right now.”
Patient's answer is:
3. Correct
2. Missed by 1 year
1. Missed by 2 to 5 years
0. Missed by more than 5 years or no answer

Rationale for Change
New items added to collect data
for function quality measures.
Risk Adjustors for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

B. Ask patient: “What month are we in right now?”
Patient's answer is:
2. Accurate within 5 days
1. Missed by 6 days to 1 month
0. Missed by more than 1 month or no answer
C. Ask patient: “What day of the week is today?”
Patient's answer is:
1. Correct
0. Incorrect or no answer
(continued)

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#
9.

Admission or
Discharge
Assessment
Admission

Item / Text
Affected
C0400A
C0400B
C0400C

IRF-PAI Version 1.3
N/A – new items

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
C0400. Recall
Ask patient: “Let's go back to the first question. What were
those three words that I asked you to repeat?” If unable to
remember a word, give cue (i.e., something to wear; a
color; a piece of furniture) for that word.
A. Recalls “sock?”
2. Yes, no cue required
1. Yes, after cueing ("something to wear")
0. No, could not recall

Rationale for Change
New items added to collect data
for function quality measures.
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

Brief Interview for Mental Status (BIMS) – Continued
B. Recalls “blue?”
2. Yes, no cue required
1. Yes, after cueing ("a color")
0. No, could not recall
C. Recalls “bed?”
2. Yes, no cue required
1. Yes, after cueing ("a piece of furniture")
0. No, could not recall
10. Admission

C0500

N/A – new item

C0500. BIMS Summary Score
Add scores for questions C0200-C0400 and fill in total
score (00-15)
Enter 99 if the patient was unable to complete the
interview

New item added to collect data for
function quality measures.
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

11. Admission

C0600

N/A – new item

C0600. Should the Staff Assessment for Mental Status
(C0900) be Conducted?
0. No (patient was able to complete Brief Interview for
Mental Status)  Skip to GG0100. Prior Functioning:
Everyday Activities
1. Yes (patient was unable to complete Brief Interview for
Mental Status)  Continue to C0900. Memory/Recall
Ability

12. Admission

C0900A
C0900B
C0900C
C0900E
C0900Z

N/A – new items

Staff Assessment for Mental Status
New items added to collect data
Do not conduct if Brief Interview for Mental Status (C0200- for function quality measures.
C0500) was completed.
Risk Adjustors for self-care change
quality measure, mobility change
C0900. Memory/Recall Ability
quality measure, discharge selfCheck all that the patient was normally able to recall
care quality measure quality
A. Current season
measure, and discharge mobility
B. Location of own room
quality measure.
C. Staff names and faces

New item added to collect data for
function quality measures.

E. That he or she is in a hospital/hospital unit
Z. None of the above were recalled

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

13. Admission

Section GG

N/A – new section header

Section GG Functional Abilities and Goals

14. Admission

GG0100A
GG0100B
GG0100C
GG0100D

N/A – new items

GG0100. Prior Functioning: Everyday Activities. Indicate
the patient's usual ability with everyday activities prior to
the current illness, exacerbation, or injury.
CODING:
3. Independent - Patient completed the activities by
him/herself, with or without an assistive device, with no
assistance from a helper.
2. Needed Some Help - Patient needed partial assistance
from another person to complete activities.
1. Dependent - A helper completed the activities for the
patient.
8. Unknown
9. Not Applicable
A. Self-Care: Code the patient’s need for assistance with
bathing, dressing, using the toilet, or eating prior to the
current illness, exacerbation, or injury.
GG0100. Prior Functioning: Everyday Activities
(Continued)
B. Indoor Mobility (Ambulation): Code the patient’s need
for assistance with walking from room to room (with or
without a device such as cane, crutch, or walker) prior to
the current illness, exacerbation, or injury.
C. Stairs: Code the patient’s need for assistance with
internal or external stairs (with or without a device such as
cane, crutch, or walker) prior to the current illness,
exacerbation, or injury.
D. Functional Cognition: Code the patient’s need for
assistance with planning regular tasks, such as shopping or
remembering to take medication prior to the current
illness, exacerbation, or injury.

Rationale for Change

New items added to collect data
for function quality measures.
Risk adjustors for the self-care
change quality measure, mobility
change quality measure, discharge
self-care quality measure, and/or
discharge mobility quality
measure.

(continued)
*Item was Voluntary on Version 1.3
July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

15. Admission

16. Admission

Item / Text
Affected

IRF-PAI Version 1.3

GG0110A
GG0110B
GG0110C
GG0110D
GG0110E
GG0110Z

N/A – new items

GG0130A
GG0130B
GG0130C
GG0130E
GG0130F
GG0130G
GG0130H

N/A – new items

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

GG0110. Prior Device Use. Indicate devices and aids used
by the patient prior to the current illness, exacerbation, or
injury.
Check all that apply
A. Manual wheelchair
B. Motorized wheelchair or scooter
C. Mechanical lift
D. Walker
E. Orthotics/Prosthetics
Z. None of the above

New items added to collect data
for function quality measures.

GG0130. Self-Care (3-day assessment period)

New items added to collect data
for function quality measures.

Risk Adjustors for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

Code the patient's usual performance at admission for
each activity using the 6-point scale. If activity was not
Admission Performance
attempted at admission, code the reason. Code the
GG0130A, GG0130B, GG0130C
patient’s discharge goal(s) using the 6-point scale. Do not
Risk adjustors for self-care change
use codes 07, 09, or 88 to code discharge goal(s).
quality measure and discharge
self-care quality measure.
CODING:
Safety and Quality of Performance - If helper assistance is Used to calculate the performance
score for self-care change quality
required because patient's performance is unsafe or of
measure and cross-setting
poor quality, score according to amount of assistance
function process quality measure.
provided.

Activities may be completed with or without assistive
devices.
06. Independent - Patient completes the activity by
him/herself with no assistance from a helper.

Admission Performance
GG0130E, GG0130F, GG0130G,
GG0130H
(continued)

*Item was Voluntary on Version 1.3
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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
05. Setup or clean-up assistance - Helper SETS UP or
CLEANS UP; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance as
patient completes activity. Assistance may be provided
throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN
HALF the effort. Helper lifts, holds or supports trunk or
limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Patient
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient
to complete the activity.

Rationale for Change
Risk adjustors for self-care change
quality measure and discharge
self-care quality measure.
Used to calculate the performance
score for self-care change quality
measure and the discharge selfcare quality measure.
Self-Care Discharge Goal (on
admission)
Used to calculate the performance
score for cross-setting function
process quality measure

If activity was not attempted, code reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical condition or safety
concerns
1. Admission Performance
2. Discharge Goal
(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food
to the mouth and swallow food once the meal is presented
on a table/tray. Includes modified food consistency.
B. Oral hygiene: The ability to use suitable items to clean
teeth. [Dentures (if applicable): The ability to remove and
replace dentures from and to the mouth, and manage
equipment for soaking and rinsing them.]
C. Toileting hygiene: The ability to maintain perineal
hygiene, adjust clothes before and after using the toilet,
commode, bedpan or urinal. If managing an ostomy,
include wiping the opening but not managing equipment.
E. Shower/bathe self: The ability to bathe self in shower
or tub, including washing, rinsing, and drying self. Does not
include transferring in/out of tub/shower.
F. Upper body dressing: The ability to put on and remove
shirt or pajama top; includes buttoning, if applicable.
G. Lower body dressing: The ability to dress and undress
below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on
and take off socks and shoes or other footwear that is
appropriate for safe mobility.
(continued)

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Admission or
Discharge
Assessment

17. Admission

Item / Text
Affected
GG0170A
GG0170B
GG0170C
GG0170D
GG0170E
GG0170F
GG0170G
GG0170H1
GG0170I
GG0170J
GG0170K
GG0170L
GG0170M
GG0170N
GG0170O
GG0170P
GG0170Q1
GG0170R
GG0170RR1
GG0170S
GG0170SS1

IRF-PAI Version 1.3
N/A – new items

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at admission for
each activity using the 6-point scale. If activity was not
attempted at admission, code the reason. Code the
patient’s discharge goal(s) using the 6-point scale. Do not
use codes 07, 09, or 88 to code discharge goal(s).
CODING:
Safety and Quality of Performance - If helper assistance is
required because patient's performance is unsafe or of
poor quality, score according to amount of assistance
provided.
Activities may be completed with or without assistive
devices.
06. Independent - Patient completes the activity by
him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper SETS UP or
CLEANS UP; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance as
patient completes activity. Assistance may be provided
throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN
HALF the effort. Helper lifts, holds or supports trunk or
limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Patient
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient
to complete the activity.

Rationale for Change
New items added to collect data
for function quality measures.
Admission Performance
GG0170B, GG0170C, GG0170D
GG0170E, GG0170F, GG0170J,
GG0170K, GG0170R, GG0170S
Risk adjustors for mobility change
quality measure and discharge
mobility quality measure.
Used to calculate the performance
score for mobility change quality
measure and mobility discharge
quality measure, and the crosssetting function process measure.
Admission Performance
GG0170A, GG0170G, GG0170I
GG0170L, GG0170M, GG0170N,
GG0170O, GG0170P
Risk adjustors for mobility change
quality measure and discharge
mobility quality measure.
Used to calculate the performance
score for mobility change quality
measure and the mobility
discharge quality measure.
(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Change Table: Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI) Version 1.3 to Version 1.4
#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
If activity was not attempted, code the reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical condition or safety
concerns
1. Admission Performance
2. Discharge Goal
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back
to left and right side, and return to lying on back.
B. Sit to lying: The ability to move from sitting on side of
bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to safely
move from lying on the back to sitting on the side of the
bed with feet flat on the floor, and with no back support.
D. Sit to stand: The ability to safely come to a standing
position from sitting in a chair or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to safely
transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to safely get on and off a
toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or
van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.

Rationale for Change
Admission Performance
GG0170RR1, GG0170SS1
Used to calculate the performance
score for mobility change quality
measure and mobility discharge
quality measure, and the crosssetting function process measure.
Mobility Discharge Goal (on
admission)
Used to calculate the performance
score for cross-setting function
process quality measure.

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

H1. Does the patient walk?
0. No, and walking goal is not clinically indicated
 Skip to GG0170Q1. Does the patient use a
wheelchair/scooter?
1. No, and walking goal is clinically indicated 
Code the patient's discharge goal(s) for items
GG0170I, J, K, L, M, N, O, and P. For admission
performance, skip to GG0170Q1. Does the patient
use a wheelchair/scooter?
2. Yes  Continue to GG0170I. Walk 10 feet
I. Walk 10 feet: Once standing, the ability to walk at least
10 feet in a room, corridor or similar space.
J. Walk 50 feet with two turns: Once standing, the ability
to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at
least 150 feet in a corridor or similar space.
L. Walking 10 feet on uneven surfaces: The ability to walk
10 feet on uneven or sloping surfaces, such as grass or
gravel.
M. 1 step (curb): The ability to step over a curb or up and
down one step.
N. 4 steps: The ability to go up and down four steps with
or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or
without a rail.
P. Picking up object: The ability to bend/stoop from a
standing position to pick up a small object, such as a
spoon, from the floor.
(continued)

*Item was Voluntary on Version 1.3
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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

Q1. Does the patient use a wheelchair/scooter?
0. No  Skip to H0350. Bladder Continence
1. Yes  Continue to GG0170R. Wheel 50 feet
with two turns
R. Wheel 50 feet with two turns: Once seated in
wheelchair/scooter, the ability to wheel at least 50 feet
and make two turns.
RR1. Indicate the type of wheelchair/scooter
used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the
ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair/scooter
used.
1. Manual
2. Motorized
18. Admission

Section H

N/A – new section header

Section H Bladder and Bowel

19. Admission

H0350

N/A – new item

H0350. Bladder continence (3-day assessment period)
Bladder continence - Select the one category that best
describes the patient.
0. Always continent (no documented incontinence)
1. Stress incontinence only
2. Incontinent less than daily (e.g., once or twice during
the 3-day assessment period)
3. Incontinent daily (at least once a day)
4. Always incontinent
5. No urine output (e.g., renal failure)
9. Not applicable (e.g., indwelling catheter)

New item added to collect data for
function quality measures.
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Admission or
Discharge
Assessment

20. Admission

Item / Text
Affected
H0400

IRF-PAI Version 1.3
N/A – new item

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
H0400. Bowel Continence (3-day assessment period)
Bowel continence - Select the one category that best
describes the patient.
0. Always continent
1. Occasionally incontinent (one episode of bowel
incontinence)
2. Frequently incontinent (2 or more episodes of bowel
incontinence, but at least one continent bowel movement)
3. Always incontinent (no episodes of continent bowel
movements)
9. Not rated, patient had an ostomy or did not have a
bowel movement for the entire 3 days

21. Admission

Section I

N/A – new section header

Section I Active Diagnoses

22. Admission

I0900
I0900A
I0900B
I2900
I2900A
I2900B*
I2900C*
I2900D*
I7900

I0900. Pressure Ulcer Risk Conditions- Admission
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.)
I0900A. Peripheral Vascular Disease (PVD)
0. No 1. Yes
I0900B. Peripheral Arterial Disease(PAD)
0. No 1. Yes
I2900A. Diabetes Mellitus (DM)
If I2900A = 0, skip I2900B-D
0. No 1. Yes
I2900B. Diabetic Retinopathy
0. No 1. Yes
I2900C. Diabetic Nephropathy
0. No 1. Yes
I2900D. Diabetic Neuropathy
0. No 1. Yes

Comorbidities and Co-existing Conditions
Check all that apply
I0900. Peripheral Vascular Disease (PVD) or Peripheral
Arterial Disease (PAD)
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy,
nephropathy, and neuropathy)
I7900. None of the above

Rationale for Change
New items added to collect data
for function quality measures.
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.

To align with the LTCH Care Data
Set V.3.00, items I0900A, I0900B,
I2900A, I2900B, I2900C, and
I2900D were deleted and replaced
with items I0900, I2900, and
I17900.
Risk Adjustors for pressure ulcer
quality measure

(continued)
*Item was Voluntary on Version 1.3
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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

23. Admission

Section J

N/A – new section header

Section J Health Conditions

24. Admission

J1750

N/A – new item

J1750. History of Falls
Has the patient had two or more falls in the past year or
any fall with injury in the past year?
0. No
1. Yes
8. Unknown

New item added to collect data for
function quality measures.

J2000. Prior Surgery
Did the patient have major surgery during the 100 days
prior to admission?
0. No
1. Yes
8. Unknown

New item added to collect data for
function quality measures.

25. Admission

J2000

N/A – new item

26. Admission

Section K

N/A – new section header

Section K Swallowing/Nutritional Status

27. Admission

K0110A
K0110B
K0110C

N/A – new item

K0110. Swallowing/Nutritional Status (3-day assessment
period) Indicate the patient's usual ability to swallow.
Check all that apply
A. Regular food - Solids and liquids swallowed safely
without supervision or modified food or liquid consistency.
B. Modified food consistency/supervision - Patient
requires modified food or liquid consistency and/or needs
supervision during eating for safety.
C. Tube/parenteral feeding - Tube/parenteral feeding
used wholly or partially as a means of sustenance.

Risk Adjustor for mobility change
quality measure, and discharge
mobility quality measure.

Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
New items added to collect data
for function quality measures.
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
(continued)

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Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

28. Admission

Section M

N/A – new section header

Section M Skin Conditions

29. Admission

M0210

Unhealed Pressure Ulcer(s)- Admission

Report based on highest stage of existing ulcer(s) at its
worst; do not "reverse" stage

M0210. Does this patient have one or more unhealed
pressure ulcer(s) at Stage 1 or higher at Admission?

Rationale for Change

Language and formatting revised
to align with the LTCH Care Data
Set V.3.00.

M0210. Unhealed Pressure Ulcer(s)
Does this patient have one or more unhealed pressure
Used to calculate pressure ulcer
0. No  skip to question I0900 on Admission Assessment ulcer(s) at Stage 1 or higher?
quality measure
1. Yes  continue to question M0300A on Admission
0. No  Skip to O0100. Special Treatments, Procedures,
Assessment
and Programs
1. Yes  Continue to M0300. Current Number of Unhealed
Pressure Ulcers at Each Stage.
30. Admission

M0300A
M0300A1*

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage- Admission
M0300A. Stage 1: Intact skin with non-blanchable redness
of 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.
M0300A1. Number of Stage 1 pressure ulcers: enter how
many were noted at the time of admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage
A. Stage 1: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. Darkly
pigmented skin may not have a visible blanching; in dark
skin tones only it may appear with persistent blue or
purple hues.
Number of Stage 1 pressure ulcers

Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.
Used to calculate pressure ulcer
quality measure.

(continued)

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Admission or
Discharge
Assessment

31. Admission

32. Admission

Item / Text
Affected
M0300B1

M0300C1

IRF-PAI Version 1.3
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.
M0300B1. Number of Stage 2 pressure ulcers: enter how
many were noted at the time of admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage- Admission, 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.
M0300C1. Number of Stage 3 pressure ulcers: enter how
many were noted at the time of admission

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage
B. 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.
1. Number of Stage 2 pressure ulcers

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

Rationale for Change
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.
Used to calculate pressure ulcer
quality measure.
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may
be visible but bone, tendon or muscle is not exposed.
Used to calculate pressure ulcer
Slough may be present but does not obscure the depth of quality measure.
tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
(continued)

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Admission or
Discharge
Assessment

33. Admission

34. Admission

Item / Text
Affected
M0300D1

M0300E1*

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

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.
M0300D1. Number of Stage 4 pressure ulcers: enter how
many were noted at the time of admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

M0300E. Unstageable Pressure Ulcers due to nonremovable dressing/device: Known but not stageable due
to the presence of a non-removable dressing/device.
M0300E1. Number of unstageable pressure ulcers due to
non-removable dressing/device: enter how many were
noted at the time of admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

Rationale for Change
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

D. Stage 4: Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be present on
Used to calculate pressure ulcer
some parts of the wound bed. Often includes undermining quality measure.
and tunneling.
1. Number of Stage 4 pressure ulcers
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

E. Unstageable - Non-removable dressing: Known but not
stageable due to non-removable dressing/device
Used to calculate pressure ulcer
1. Number of unstageable pressure ulcers due to nonquality measure.
removable dressing/device
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
(continued)

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Admission or
Discharge
Assessment

35. Admission

36. Admission

Item / Text
Affected
M0300F1*

M0300G1*

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

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.
M0300F1. Number of unstageable pressure ulcers due to
slough and/ or eschar: enter how many were noted at the
time of admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

M0300G. Unstageable Pressure Ulcers with Suspected
Deep Tissue Injury (DTI) in evolution: suspected deep
tissue injury in evolution.
M0300G1. Number of unstageable pressure ulcers with
Suspected Deep Tissue Injury in evolution: enter how
many were noted at the time of admission

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

Rationale for Change
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

F. Unstageable - Slough and/or eschar: Known but not
stageable due to coverage of wound bed by slough and/or Used to calculate pressure ulcer
eschar
quality measure.
1. Number of unstageable pressure ulcers due to
coverage of wound bed by slough and/or eschar
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

G. Unstageable - Deep tissue injury: Suspected deep
tissue injury in evolution
Used to calculate pressure ulcer
1. Number of unstageable pressure ulcers with suspected quality measure.
deep tissue injury in evolution
Risk Adjustor for self-care change
quality measure, mobility change
quality measure, discharge selfcare quality measure, and
discharge mobility quality
measure.
(continued)

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Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

37. Admission

Section O

N/A – new section header

Section O Special Treatments, Procedures, and Programs

38. Admission

O0100

N/A – new item

O0100. Special Treatments, Procedures, and Programs
Check if treatment applies at admission
N. Total Parenteral Nutrition

39. Discharge

Section GG

N/A – new section header

Section GG Functional Abilities and Goals

40. Discharge

GG0130A
GG0130B
GG0130C
GG0130E
GG0130F
GG0130G
GG0130H

N/A – new items

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at discharge for
each activity using the 6-point scale. If activity was not
attempted at discharge, code the reason.
CODING:
Safety and Quality of Performance - If helper assistance is
required because patient's performance is unsafe or of
poor quality, score according to amount of assistance
provided.
Activities may be completed with or without assistive
devices.
06. Independent - Patient completes the activity by
him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper SETS UP or
CLEANS UP; patient completes activity. Helper assists only
prior to or following the activity.
04. Supervision or touching assistance - Helper provides
VERBAL CUES or TOUCHING/STEADYING assistance as
patient completes activity. Assistance may be provided
throughout the activity or intermittently.

Rationale for Change

New items added to collect data
for function quality measures.
Risk Adjustor for mobility change
quality measure, and discharge
mobility quality measure.
New items added to collect data
for function quality measures.
Self-Care Discharge Performance
GG0130A, GG0130B, GG0130C
Used to calculate the performance
score for self-care change quality
measure, discharge self-care
quality measure, and cross-setting
function process quality measure.
Self-Care Discharge Performance
GG0130E, GG0130F, GG0130G,
GG0130H
Used to calculate the performance
score for self-care change quality
measure and discharge self-care
quality measure.
(continued)

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Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

03. Partial/moderate assistance - Helper does LESS THAN
HALF the effort. Helper lifts, holds or supports trunk or
limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Patient
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient
to complete the activity.
If activity was not attempted, code the reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical condition or safety
concerns
3. Discharge Performance
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food
to the mouth and swallow food once the meal is presented
on a table/tray. Includes modified food consistency.
B. Oral hygiene: The ability to use suitable items to clean
teeth. [Dentures (if applicable): The ability to remove and
replace dentures from and to the mouth, and manage
equipment for soaking and rinsing them.]
C. Toileting hygiene: The ability to maintain perineal
hygiene, adjust clothes before and after using the toilet,
commode, bedpan or urinal. If managing an ostomy,
include wiping the opening but not managing equipment.
(continued)

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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

E. Shower/bathe self: The ability to bathe self in shower
or tub, including washing, rinsing, and drying self. Does not
include transferring in/out of tub/shower.
F. Upper body dressing: The ability to put on and remove
shirt or pajama top; includes buttoning, if applicable.
G. Lower body dressing: The ability to dress and undress
below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on
and take off socks and shoes or other footwear that is
appropriate for safe mobility.
41. Discharge

GG0170A
GG0170B
GG0170C
GG0170D
GG0170E
GG0170F
GG0170G
GG0170H3
GG0170I
GG0170J
GG0170K
GG0170L
GG0170M
GG0170N
GG0170O
GG0170P
GG0170Q3
GG0170R
GG0170RR3
GG0170S
GG0170SS3

N/A – new items

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at discharge for
each activity using the 6-point scale. If activity was not
attempted at discharge, code the reason.

New items added to collect data
for function quality measures.

Discharge Performance
GG0170B, GG0170C, GG0170D
CODING:
GG0170E, GG0170F, GG0170J,
Safety and Quality of Performance - If helper assistance is GG0170K, GG0170R, GG0170S
required because patient's performance is unsafe or of
poor quality, score according to amount of assistance
Used to calculate the performance
provided.
score for mobility change quality
Activities may be completed with or without assistive
measure, mobility discharge
devices.
quality measure, and the cross06. Independent - Patient completes the activity by
setting function process measure.
him/herself with no assistance from a helper.
GG0170RR3, GG0170SS3
05. Setup or clean-up assistance - Helper SETS UP or
CLEANS UP; patient completes activity. Helper assists only
Used to calculate the performance
prior to or following the activity.
score for the cross-setting
04. Supervision or touching assistance - Helper provides
function measure.
VERBAL CUES or TOUCHING/STEADYING assistance as
patient completes activity. Assistance may be provided
throughout the activity or intermittently.
(continued)

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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
03. Partial/moderate assistance - Helper does LESS THAN
HALF the effort. Helper lifts, holds or supports trunk or
limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Patient
does none of the effort to complete the activity. Or, the
assistance of 2 or more helpers is required for the patient
to complete the activity.
If activity was not attempted, code the reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical condition or safety
concerns

Rationale for Change
Discharge Performance
GG0170A, GG0170G, GG0170I
GG0170L, GG0170M, GG0170N,
GG0170O, GG0170P
Used to calculate the performance
score for mobility change quality
measure and the mobility
discharge quality measure.

3. Discharge Performance
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back
to left and right side, and return to lying on back.
B. Sit to lying: The ability to move from sitting on side of
bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to safely
move from lying on the back to sitting on the side of the
bed with feet flat on the floor, and with no back support.
D. Sit to stand: The ability to safely come to a standing
position from sitting in a chair or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to safely
transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to safely get on and off a
toilet or commode.
(continued)
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Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

G. Car transfer: The ability to transfer in and out of a car or
van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.
H3. Does the patient walk?
0. No  Skip to GG0170Q3. Does the patient use
a wheelchair/scooter?
2. Yes  Continue to GG0170I. Walk 10 feet
I. Walk 10 feet: Once standing, the ability to walk at least
10 feet in a room, corridor or similar space
J. Walk 50 feet with two turns: Once standing, the ability
to walk at least 50 feet and make two turns
K. Walk 150 feet: Once standing, the ability to walk at
least 150 feet in a corridor or similar space
L. Walking 10 feet on uneven surfaces: The ability to walk
10 feet on uneven or sloping surfaces, such as grass or
gravel.
M. 1 step (curb): The ability to step over a curb or up and
down one step.
N. 4 steps: The ability to go up and down four steps with
or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or
without a rail.
P. Picking up object: The ability to bend/stoop from a
standing position to pick up a small object, such as a
spoon, from the floor.
Q3. Does the patient use a wheelchair/scooter?
0. No  Skip to J1800. Any Falls Since Admission
1. Yes  Continue to GG0170R. Wheel 50 feet
with two turns
(continued)

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Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

R. Wheel 50 feet with two turns: Once seated in
wheelchair/scooter, the ability to wheel at least 50 feet
and make two turns.
RR3. Indicate the type of wheelchair/scooter
used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the
ability to wheel at least 150 feet in a corridor or similar
space.
SS3. Indicate the type of wheelchair/scooter
used.
1. Manual
2. Motorized
42. Discharge

Section J

N/A – new section header

Section J Health Conditions

43. Discharge

J1800

N/A – new item

J1800. Any Falls Since Admission
Has the patient had any falls since admission?
0. No  Skip to M0210. Unhealed Pressure Ulcer(s)
1. Yes  Continue to J1900. Number of Falls Since
Admission

Used to calculate falls quality
measure.

(continued)

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Admission or
Discharge
Assessment

44. Discharge

Item / Text
Affected
J1900

IRF-PAI Version 1.3
N/A – new items

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
J1900. Number of Falls Since Admission
Enter Codes in Boxes

Rationale for Change
Used to calculate falls quality
measure.

CODING:
0. None
1. One
2. Two or more
A. No injury: No evidence of any injury is noted on physical
assessment by the nurse or primary care clinician; no
complaints of pain or injury by the patient; no change in
the patient's behavior is noted after the fall
B. Injury (except major): Skin tears, abrasions, lacerations,
superficial bruises, hematomas and sprains; or any fallrelated injury that causes the patient to complain of pain
C. Major injury: Bone fractures, joint dislocations, closed
head injuries with altered consciousness, subdural
hematoma
45. Discharge

Section M

N/A – new section header

Section M Skin Conditions

46. Discharge

M0210

Unhealed Pressure Ulcer(s)- Discharge

Report based on highest stage of existing ulcer(s) at its
worst; do not "reverse" stage

M0210. Does this patient have one or more unhealed
pressure ulcer(s) at Stage 1 or higher on Discharge?
0. No  skip to question M0900A on Discharge
Assessment
1. Yes  continue to question M0300A on Discharge
Assessment

Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

M0210. Does this patient have one or more unhealed
Used to calculate pressure ulcer
pressure ulcer(s) at Stage 1 or higher?
quality measure.
0. No  Skip to M0900A. Healed Pressure Ulcer(s)
1. Yes  Continue to M0300. Current Number of Unhealed
Pressure Ulcers at Each Stage
(continued)

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Admission or
Discharge
Assessment

47. Discharge

Item / Text
Affected
M0300A
M0300A1*
M0300A2*
M0300A3*

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage- Discharge

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

M0300A. Stage 1: Intact skin with non-blanchable redness
of 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.
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.
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)

A. Stage 1: Intact skin with non-blanchable redness of a
localized area usually over a bony prominence. Darkly
pigmented skin may not have a visible blanching; in dark
skin tones only it may appear with persistent blue or
purple hues.
Number of Stage 1 pressure ulcers

Rationale for Change
To align language and formatting
with the LTCH Care Data Set
V.3.00, items M0300A2 and
M0300A3 were deleted.
Used to calculate pressure ulcer
quality measure.

(continued)

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Admission or
Discharge
Assessment

48. Discharge

Item / Text
Affected
M0300B1
M0300B2*
M0300B3*
M0300B4

IRF-PAI Version 1.3
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.
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.)
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

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)
M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage
B. 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.
1. Number of Stage 2 pressure ulcers
If 0  Skip to M0300C. Stage 3

Rationale for Change
To align language and formatting
with the LTCH Care Data Set
V.3.00, item M0300B3 was
deleted. Item M0300B4 was
deleted and replaced with
M0800A (see below).
Used to calculate pressure ulcer
quality measure.

2. Number of these Stage 2 pressure ulcers that were
present upon admission - enter how many were noted at
the time of admission

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Admission or
Discharge
Assessment

49. Discharge

Item / Text
Affected
M0300C1
M0300C2*
M0300C3*
M0300C4

IRF-PAI Version 1.3
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. Enter total number of pressure ulcers currently
at Stage 3. (If patient has no Stage 3 pressure ulcers at
discharge, skip to Item M0300D1.
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-removeable device at admission,
initially became stageable at a lesser stage, but then
progressed to a Stage 3 by the time of discharge.

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

To align language and formatting
with the LTCH Care Data Set
V.3.00, items M0300C3 was
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may deleted. Item M0300C4 was
be visible but bone, tendon or muscle is not exposed.
deleted and replaced with
Slough may be present but does not obscure the depth of M0800B (see below).
tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers
Used to calculate pressure ulcer
If 0  Skip to M0300D. Stage 4
quality measure.
2. Number of these Stage 3 pressure ulcers that were
present upon admission - enter how many were noted at
the time of admission

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Admission or
Discharge
Assessment

50. Discharge

Item / Text
Affected
M0300D1
M0300D2*
M0300D3*
M0300D4

IRF-PAI Version 1.3
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.
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.
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.
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.

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

To align language and formatting
with the LTCH Care Data Set
V.3.00, items M0300D3 was
D. Stage 4: Full thickness tissue loss with exposed bone,
deleted. Item M0300D4 was
tendon or muscle. Slough or eschar may be present on
deleted and replaced with
some parts of the wound bed. Often includes undermining M0800C (see below).
and tunneling.
1. Number of Stage 4 pressure ulcers
Used to calculate pressure ulcer
If 0  Skip to M0300E. Unstageable - Non-removable
quality measure.
dressing
2. Number of these Stage 4 pressure ulcers that were
present upon admission - enter how many were noted at
the time of admission

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Admission or
Discharge
Assessment

51. Discharge

Item / Text
Affected
M0300E1*
M0300E2*
M0300E3*

IRF-PAI Version 1.3
M0300E. Unstageable Pressure Ulcers due to a nonremovable dressing or device: pressure ulcers that are
known but not stageable due to the presence of a nonremovable dressing or device.
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.)
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.
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.

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

To align language and formatting
with the LTCH Care Data Set
V.3.00, item M0300E3 was
E. Unstageable - Non-removable dressing: Known but not deleted, and replaced with
stageable due to non-removable dressing/device
M0800D (see below).
1. Number of unstageable pressure ulcers due to nonremovable dressing/device
Used to calculate pressure ulcer
If 0  Skip to M0300F. Unstageable - Slough and/or
quality measure.
eschar.
2. Number of these unstageable pressure ulcers that
were present upon admission - enter how many were
noted at the time of admission

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Admission or
Discharge
Assessment

52. Discharge

Item / Text
Affected
M0300F1*
M0300F2*
M0300F3*

IRF-PAI Version 1.3
M0300F. Unstageable Pressure Ulcers due to slough or
eschar: pressure ulcers that are known but not stageable
due to coverage of wound bed by slough and/or eschar.
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.

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

To align language and formatting
with the LTCH Care Data Set
V.3.00, item M0300F3 was
F. Unstageable - Slough and/or eschar: Known but not
deleted, and replaced with
stageable due to coverage of wound bed by slough and/or M0800E (see below).
eschar
1. Number of unstageable pressure ulcers due to
Used to calculate pressure ulcer
coverage of wound bed by slough and/or eschar
quality measure.
If 0  Skip to M0300G. Unstageable - Deep tissue injury
2. Number of these unstageable pressure ulcers that
were present upon admission - enter how many were
noted at the time of admission

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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Admission or
Discharge
Assessment

53. Discharge

54. Discharge

Item / Text
Affected
M0300G1*
M0300G2*

M0800A
M0800B
M0800C
M0800D
M0800E
M0800F

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

M0300G. Unstageable Pressure Ulcers with Suspected
Deep Tissue Injury (DTI) in evolution: suspected deep
tissue injury in evolution.
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.)
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.

M0300. Current Number of Unhealed Pressure Ulcers at
Each Stage

N/A – New item

M0800. Worsening in Pressure Ulcer Status Since
Admission
Indicate the number of current pressure ulcers that were
not present or were at a lesser stage on admission.
If no current pressure ulcer at a given stage, enter 0.
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable - Non-removable dressing
E. Unstageable - Slough and/or eschar
F. Unstageable - Deep tissue injury

Rationale for Change
Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.

G. Unstageable - Deep tissue injury: Suspected deep
tissue injury in evolution
Used to calculate pressure ulcer
1. Number of unstageable pressure ulcers with suspected quality measure.
deep tissue injury in evolution
If 0  Skip to M0800. Worsening in Pressure Ulcer Status
Since Admission
2. Number of these unstageable pressure ulcers that
were present upon admission - enter how many were
noted at the time of admission
To align language and formatting
with the LTCH Care Data Set
V.3.00, items M0800A, M0800B,
M0800C, M0800D, M0800E, and
M0800F were added.
Used to calculate pressure ulcer
quality measure.

(continued)

*Item was Voluntary on Version 1.3
July 30, 2015

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#

Admission or
Discharge
Assessment

55. Discharge

Item / Text
Affected

IRF-PAI Version 1.3

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

M0900A*
M0900B*
M0900C*
M0900D*

M0900. Healed Pressure Ulcers- Discharge
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.
M0900A. Stage 1
M0900B. Stage 2
M0900C. Stage 3
M0900D. Stage 4

M0900. Healed Pressure Ulcer(s)
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.
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

56. Discharge

Section O

N/A – new section header

Section O Special Treatments, Procedures, and Programs

57. Discharge

O0250A
O0250B
O0250C

O0250. Influenza Vaccine – Discharge - Refer to current
version of IRF-PAI Training Manual for current influenza
vaccination season and reporting period.

O0250. Influenza Vaccine - Refer to current version of
Revised to align language and
IRF-PAI Training Manual for current influenza vaccination formatting with the LTCH Care
season and reporting period.
Data Set V.3.00.

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

A. 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

Revised to align language and
formatting with the LTCH Care
Data Set V.3.00.
Used to calculate pressure ulcer
quality measure.

Used to calculate patient influenza
vaccination quality measure.

O0250B. Date influenza vaccine received  Complete
B. Date influenza vaccine received  Complete date and
date and skip to Z0400A, Signature of Persons Completing skip to Z0400A. Signature and Persons Completing the
the Assessment
Assessment.
(continued)

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July 30, 2015

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#

Admission or
Discharge
Assessment

Item / Text
Affected

IRF-PAI Version 1.3
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

*Item was Voluntary on Version 1.3
July 30, 2015

IRF-PAI Version 1.4
(All Version 1.4 items are Mandatory)

Rationale for Change

C. 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

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