Form CMS-10036 Proposed IRF QRP New and Modified Items

Proposed IRF QRP New and Modified Items – Effective Date: October 1, 2020

Identification Information
15A. Admit From

_____________

(01. Home (e.g. private home/apt., board/care, assisted living, group home, transitional living, other residential care
arrangements); 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 (medical 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 (CAH); 99. Not Listed

Discharge Information
44D. Patient’s discharge destination/living setting, using codes below:
(answer only if 44C = 1; if 44C = 0, skip to item 46)

______________

(01. Home (e.g. private home/apt., board/care, assisted living, group home, transitional living, other residential care
arrangements); 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 (medical 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 (CAH); 99. Not Listed

ADMISSION
Section A

Administrative Information

A1005. Ethnicity
Are you Hispanic, Latino/a, or Spanish origin?
Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, Another Hispanic, Latino, or Spanish origin
X. Patient unable to respond

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

A1010. Race
What is your race?
Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I. Vietnamese
J. Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Patient unable to respond
A1110. Language
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care
staff?
0. No
1. Yes
9. Unable to determine

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I
need
C. No
D. Patient unable to respond

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section B

Hearing, Speech, and Vision

B0200. Hearing
Ability to hear (with hearing aid or hearing appliances if normally used)
Enter Code
0. Adequate – no difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty – difficulty in some environments (e.g., when person speaks softly or
setting is noisy)
2. Moderate difficulty – speaker has to increase volume and speak distinctly
3. Highly impaired – absence of useful hearing
B1000. Vision
Ability to See in Adequate Light (with glasses or other visual appliances)
0. Adequate – sees fine detail, such as regular print in newspapers/books
Enter Code
1. Impaired – sees large print, but not regular print in newspapers/books
2. Moderately impaired – limited vision; not able to see newspaper headlines but can identify
objects
3. Highly impaired – object identification in question, but eyes appear to follow objects
4. Severely impaired – no vision or sees only light, colors or shapes; eyes do not appear to
follow objects
B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other
written material from your doctor or pharmacy?
0. Never
Enter Code 1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section C

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical
record.
A. Acute Onset Mental Status Change
Enter Code Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes
Coding:
0. Behavior not
present
1. Behavior
continuously
present, does
not fluctuate
2. Behavior
present,
fluctuates
(comes and
goes, changes
in severity)

Enter Code in Boxes

B. Inattention - Did the patient have difficulty focusing attention,
for example, being easily distractible or having difficulty keeping
track of what was being said?
C. Disorganized thinking - Was the patient's thinking disorganized
or incoherent (rambling or irrelevant conversation, unclear or
illogical flow of ideas, or unpredictable switching from subject to
subject)?
D. Altered level of consciousness - Did the patient have altered
level of consciousness as indicated by any of the following
criteria?
 vigilant - startled easily to any sound or touch
 lethargic - repeatedly dozed off when being asked questions, but
responded to voice or touch
 stuporous - very difficult to arouse and keep aroused for the interview
 comatose - could not be aroused
Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section D

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2,
Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
2.
1.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Frequency
Presence
2. 7-11 days (half or more of the
9. No response (leave column 2
days)
blank)
Enter Scores in Boxes
3. 12-14 days(nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END
the PHQ interview and SKIP to next section.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have
let yourself or your family down
G. Trouble concentrating on things, such as reading the
newspaper or watching television
H. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless
that you have been moving around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting
yourself in some way
D0160. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must
be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more
required items)

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
0. Never
1. Rarely
Enter Code
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

Section J

Health Conditions

J0510. Pain Effect on Sleep

Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to sleep
at night?”
0. Does not apply – I have not had any pain or hurting in the past 5 days  Skip to
XXXX
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0520. Pain Interference with Therapy Activities

Enter code

Ask patient: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0530. Pain Interference with Day-to-Day Activities

Enter code

Ask patient: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply on admission.
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet – require change in texture of food or liquids (e.g.,
pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications
in the following drug classes
2. Indication noted
If Column 1 is checked, check if there is an
indication noted for all medications in the drug
class

1. Is taking

2. Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy Care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the Above

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

DISCHARGE
Section A

Administrative Information

A1110. Language
A. What is your preferred language?
Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care
staff?
0. No
1. Yes
9. Unable to determine

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things
that I need
C. No
D. Patient unable to respond
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the patient’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

A2122. Provision of Current Reconciled Medication List to Patient at Discharge
At the time of discharge, did your facility provide the patient’s current reconciled medication list to the
patient, family and/or caregiver?
Enter Code
1. No – Current reconciled medication list not provided to the patient, family and/or
caregiver
2. Yes – Current reconciled medication list provided to the patient, family and/or
caregiver

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

A2123. Route of Current Reconciled Medication List Transmission
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
and/or patient/family/caregiver.
1.
2.
To subsequent
To patient/
Route of Transmission
provider
family/caregiver
Check all that apply
A. Electronic Health Record
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video
conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)

Section B

Hearing, Speech, and Vision

B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other
written material from your doctor or pharmacy?
0. Never
Enter Code 1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? (3-day assessment
period)
Attempt to conduct interview with all patients.
Enter Code

0. No (patient is rarely/never understood) Skip to XXXX
1. Yes Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
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 after first attempt
Enter Code
3. Three
2. Two
1. One
0. None
After the patient's first attempt, repeat the words using cues ("sock, something to wear;
blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Ask patient: “Please tell me what year it is right now.”
A. Able to report correct year
Enter Code
3. Correct
2. Missed by 1 year
1. Missed by 2 - 5 years
0. Missed by > 5 years or no answer
Ask patient: “What month are we in right now?”
Enter Code B. Able to report correct month
2. Accurate within 5 days
1. Missed by 6 days to 1 month
0. Missed by > 1 month or no answer
Ask patient: “What day of the week is today?”
Enter Code
C. Able to report correct day of the week
1. Correct
0. Incorrect or no answer

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

C0400. Recall
Ask patient: “Let's go back to an earlier question. What were those three words that I asked you to
repeat?” If unable to remember a word, give cue (something to wear; a color; a piece of
furniture) for that word.
Enter Code A. Able to recall “sock”
2. Yes, no cue required
1. Yes, after cueing ("something to wear")
0. No - could not recall
B. Able to recall “blue”
Enter Code
2. Yes, no cue required
1. Yes, after cueing ("a color")
0. No - could not recall
C. Able to recall “bed”
Enter Code
2. Yes, no cue required
1. Yes, after cueing ("a piece of furniture")
0. No - could not recall
C0500. BIMS Summary Score
Enter 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
C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset Mental Status Change
Enter Code Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes
Coding:
0. Behavior not
present
1. Behavior
continuously
present, does
not fluctuate
2. Behavior
present,
fluctuates
(comes and
goes, changes
in severity)

Enter Code in Boxes
B. Inattention - Did the patient have difficulty focusing attention, for
example, being easily distractible or having difficulty keeping track
of what was being said?
C. Disorganized thinking - Was the patient's thinking disorganized or
incoherent (rambling or irrelevant conversation, unclear or illogical
flow of ideas, or unpredictable switching from subject to subject)?
D. Altered level of consciousness - Did the patient have altered level
of consciousness as indicated by any of the following criteria?
 vigilant - startled easily to any sound or touch
 lethargic - repeatedly dozed off when being asked questions, but
responded to voice or touch
 stuporous - very difficult to arouse and keep aroused for the
interview
 comatose - could not be aroused

Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.
IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section D

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2,
Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence Frequency
9. No response (leave column 2
2. 7-11 days (half or more of the
Enter Scores in Boxes
blank)
days)
3. 12-14 days(nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END
the PHQ interview and SKIP to next section.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have
let yourself or your family down
G. Trouble concentrating on things, such as reading the
newspaper or watching television
H. Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless
that you have been moving around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting
yourself in some way
D0160. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must
be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more
required items)

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
0. Never
Enter Code
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

Section J

Health Conditions

J0510. Pain Effect on Sleep

Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to sleep
at night?”
0. Does not apply – I have not had any pain or hurting in the past 5 days  Skip to
XXXX
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0520. Pain Interference with Therapy Activities

Enter code

Ask patient: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0530. Pain Interference with Day-to-Day Activities

Enter code

Ask patient: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
1. Last 7 days
Check all of the nutritional approaches that
were received in the last 7 days
2. At discharge
Check all of the nutritional approaches that
were being received at discharge

1. Last 7 days

2. At discharge

Check all that apply

Check all that apply

1. Is taking

2. Indication noted

Check all that apply

Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal
(PEG))
C. Mechanically altered diet – require change in
texture of food or liquids (e.g., pureed
food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low
cholesterol)
Z. None of the above

Section N

Medications

N0420. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications in
the following drug classes
2. Indication noted
If Column 1 is checked, check if there is an
indication noted for all medications in the drug
class
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy Care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
None of the Above
Z1. None of the above

IRF QRP New and Modified Item Mockups as delineated in the FY 2020 IRF PPS Proposed Rule, Proposed Effective Date: October 1,
2020