Form CMS-10036 IRF- PAI vesion 4.0

Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities (CMS-10036)

Final IRF-PAI Version 3.0 - Effective October 1 2019

Inpatient Rehabilitation Facility - Patient Assessment Instrument

OMB: 0938-0842

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0842
____________________________________________________________________________________________________________________________________
CENTER
FOR MEDICARE & MEDICAID SERVICES

INPATIENT REHABILITATION FACILITY - PATIENT ASSESSMENT INSTRUMENT
Identification Information
1.

Payer Information

Facility Information
A. Facility Name

_____________________________________________________________

20. Payment Source
(02 - Medicare Fee For Service; 51- Medicare-Medicare Advantage;
99 - Not Listed)

_____________________________________________________________

A. Primary Source

_________

B. Secondary Source

_________

_____________________________________________________________
Medical Information

_____________________________________________________________
_____________________________________________________________

________
Admission

21. Impairment Group*

B. Facility Medicare Provider Number ________________________
2.

Patient Medicare Number ____ ________________________________

Patient Medicaid Number ____________________________________

Patient First Name _________________________________________

5A. Patient Last Name _________________________________________
5B. Patient Identification Number ________________________________
6.

Birth Date

Social Security Number _____________________________________

Gender (1 - Male; 2 - Female) ________________________________

Race/Ethnicity (Check all that apply)

____/____/_______
MM / DD / YYYY

________
Discharge

Condition requiring admission to rehabilitation; code according to Appendix A.
A. ______
B. ______
C. ______

22. Etiologic Diagnosis
(Use ICD codes 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.

American Indian or Alaska Native

A. ________

Asian

B. ________

Black or African American

C. ________

Hispanic or Latino

D. ________

Native Hawaiian or Other Pacific Islander
White

E. ________
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

______________
14. Admission Class
(1 - Initial Rehab; 2 - Evaluation; 3 - Readmission;
4 - Unplanned Discharge; 5 - Continuing Rehabilitation)
______________
15A. Admit From
(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

24A. Are there any arthritis conditions recorded in items #21, #22, or #24 that meet
all of the regulatory requirements for IRF classification (in 42 CFR
______ __________
412.29(b)(2)(x), (xi), and (xii))?
(0 - No; 1 - Yes)
25.

DELETED

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.)
27. DELETED
28. DELETED
29. through 39.

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
* The impairment codes incorporated or referenced herein are the property of U B Foundation Activities, Inc. ©1993, 2001 U B Foundation Activities, Inc.

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Page 1

Therapy Information

____/____/________
MM / DD / YYYY

41. Patient discharged against medical advice?
42. Program Interruption(s)

______________
(0 - No; 1 - Yes)
______________
(0 - No; 1 - Yes)

43. Program Interruption Dates
(Code only if item 42 is 1 - Yes)
A. 1st Interruption Date

C. 2 Interruption Date

a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

O0401B: Occupational Therapy
B. 1st Return Date
MM / DD / YYYY

MM / DD / YYYY
nd

O0401. Week 1: Total Number of Minutes Provided
O0401A: Physical Therapy

a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

D. 2 Return Date
O0401C: Speech-Language Pathology

MM / DD / YYYY
E. 3rd Interruption Date

MM / DD / YYYY
F. 3rd Return Date

MM / DD / YYYY

a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

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

O0402. Week 2: Total Number of Minutes Provided
O0402A: Physical Therapy
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

O0402B: Occupational Therapy
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

_____________

(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)

O0402C: Speech-Language Pathology
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

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. ____________

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OMB No. 0938-0842
Patient

Identifier

Date

INPATIENT REHABILITATION FACILITY - PATIENT ASSESSMENT INSTRUMENT
QUALITY INDICATORS
ADMISSION
Section B

Hearing, Speech, and Vision

BB0700. Expression of Ideas and Wants (3-day assessment period)
Enter Code

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.

BB0800. Understanding Verbal and Non-Verbal Content (3-day assessment period)
Enter Code

Understanding Verbal and Non-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

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 C0900, Memory/Recall Ability
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.”
Enter Code

Number of words repeated after first attempt
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.

Quality Indicators - Admission
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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section C

Cognitive Patterns

Brief Interview for Mental Status (BIMS) - Continued
C0300. Temporal Orientation (orientation to year, month, and day)

Enter Code

Ask patient: “Please tell me what year it is right now.”
A. Able to report correct year
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?”
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?”
C. Able to report correct day of the week
1. Correct
0. Incorrect or no answer

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

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”
2. Yes, no cue required
1. Yes, after cueing ("a color")
0. No - could not recall
C. Able to recall “bed”
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.

C0600. Should the Staff Assessment for Mental Status (C0900) be Conducted?
Enter Code

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.

Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed..

C0900. Memory/Recall Ability (3-day assessment period)
Check all that the patient was normally able to recall.
A. Current season.
B. Location of own room.
C. Staff names and faces.
E. That he or she is in a hospital/hospital unit.
Z. None of the above were recalled.

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Enter Codes in Boxes.
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.
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.

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 and/or scooter.
C. Mechanical lift.
D. Walker.
E. Orthotics/Prosthetics.
Z. None of the above.

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

GG0130. Self-Care (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. Use of codes 07, 09, 10, or 88 is permissible 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 and/or touching/steadying and/or contact guard 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.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

1.
Admission
Performance.

2.
Discharge
Goal.

Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or
liquid once the meal is placed before the patient.

B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.

C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.

E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of
back and hair). Does not include transferring in/out of tub/shower.

F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, 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; including fasteners, if applicable.

Quality Indicators - Admission
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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

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. Use of codes 07, 09, 10, or 88 is permissible 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 and/or touching/steadying and/or contact guard 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.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
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 on the
bed.
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 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 come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to 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.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
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.

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period) - Continued
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. Use of codes 07, 09, 10, or 88 is permissible 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 and/or touching/steadying and/or contact guard 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.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns
1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor),
such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object
N. 4 steps: The ability to go up and down four steps with or without a rail.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object
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.
Q1. Does the patient use a wheelchair and/or scooter?
Skip to H0350, Bladder Continence
0. No
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 or 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 or scooter used.
1. Manual
2. Motorized

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section H

Bladder and Bowel

H0350. Bladder Continence (3-day assessment period)
Enter Code

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)

H0400. Bowel Continence (3-day assessment period)
Enter Code

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.

Section I

Active Diagnoses

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

Section J

Health Conditions

J1750. History of Falls
Enter Code

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

J2000. Prior Surgery
Enter Code

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

Section K

Swallowing/Nutritional Status

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.

Quality Indicators - Admission
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Page 9

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N2001, Drug Regimen Review
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
1. Yes

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

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..
1. Number of Stage 1 pressure injuries

Enter Number

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

Enter Number

C. 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.
1. Number of Stage 3 pressure ulcers

Enter Number

D. 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.
1. Number of Stage 4 pressure ulcers

Enter Number

E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Enter Number

F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

Enter Number

G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury

Section N

Medications

N2001. Drug Regimen Review
Enter Code

Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review
Skip to O0100, Special Treatments, Procedures, and Programs
Continue to N2003, Medication Follow-up
1. Yes - Issues found during review
9. NA - Patient is not taking any medications
Skip to O0100, Special Treatments, Procedures, and Programs

N2003. Medication Follow-up
Enter Code

Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?
0. No
1. Yes

Section O

Special Treatments, Procedures, and Programs

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

Quality Indicators - Admission
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Page 10

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section GG

Functional Abilities and Goals

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. If the patient has an incomplete stay, skip discharge GG0130 items.
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 and/or touching/steadying and/or contact guard 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.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
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 and/or liquid to the mouth and swallow food and/or liquid once
the meal is placed before the patient.

B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.

C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment.

E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and
hair). Does not include transferring in/out of tub/shower.

F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, 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; including fasteners, if applicable.

Quality Indicators - Admission
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Page 11

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section GG

Functional Abilities and Goals

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. If the patient has an incomplete stay, skip discharge GG0170 items.
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 and/or touching/steadying and/or contact guard 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.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

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 on the bed.
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 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 come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to 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.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
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.

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Page 12

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period) - Continued
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. If the patient has an incomplete stay, skip discharge GG0170 items.
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 and/or touching/steadying and/or contact guard 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.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.
Discharge.
Performance
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such
as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object
N. 4 steps: The ability to go up and down four steps with or without a rail.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object
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 and/or scooter?
Skip to J1800, Any Falls Since Admission
0. No
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.
RR3. Indicate the type of wheelchair or 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 or scooter used.
1. Manual
2. Motorized

Quality Indicators - Admission
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Page 13

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section J

Health Conditions

J1800. Any Falls Since Admission .
Enter Code

Has the patient had any falls since admission?
0. No
Skip to M0210, Unhealed Pressure Ulcers/Injuries
1. Yes
Continue to J1900, Number of Falls Since Admission .

J1900. Number of Falls Since Admission.
Coding:
0. None
1. One
2. Two or more

Enter Codes in Boxes.
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
fall-related injury that causes the patient to complain of pain
C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural
hematoma

Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N2005, Medication Intervention
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
Number
these Stage
pressure
ulcers that
admission
- enter
how many
were noted
at themay
timebe
of
C. 2.
Stage
3: Fullof
thickness
tissue2loss.
Subcutaneous
fatwere
may present
be visibleupon
but bone,
tendon
or muscle
is not exposed.
Slough
admission
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers
If 0
Skip to M0300D, Stage 4.
2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
D. 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.
1. Number of Stage 4 pressure ulcers
If 0
Skip to M0300E, Unstageable - Non-removable dressing/device..
2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission

Quality Indicators - Admission
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Page 14

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
Enter Number

1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
If 0
Skip to M0300F, Unstageable - Slough and/or eschar.
Enter Number

Enter Number

2. Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at
the time of admission
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
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
G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury
If 0
Skip to N2005, Medication Intervention

Enter Number

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

Section N

Medications

N2005. Medication Intervention
Enter Code

Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No
1. Yes
9. NA - There were no potential clinically significant medication issues identified since admission or patient is not taking
any medications.

Quality Indicators - Admission
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Page 15

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.

Final IRF-PAI Version 3.0 - Effective October 1, 2019

Page 16

File Type	application/pdf
File Title	Final Inpatient Rehabilitation Facility-Patient Assessment Instrument Version 3.0 - Effective October 1, 2019
Subject	Final Inpatient Rehabilitation Facility-Patient Assessment Instrument Version 3.0 - Effective October 1, 2019
Author	Centers for Medicare & Medicaid Services
File Modified	2020-09-23
File Created	2018-07-13