Inpatient Psychiatric Facilities Patient Assessment Instrument (IPF-PAI) Version 1.0 – Admission

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Inpatient Psychiatric Facilities Patient Assessment Instrument (IPF-PAI) Version 1.0 - Admission
Admission assessment period is the first three (3) calendar days of the IPF stay (includes day of admission and two (2) calendar days after).

Section A

Identification Information

A0050. Type of Record
Enter Code

1. Add new record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers
A. National Provider Identifier (NPI)

B. CMS Certification Number (CCN):

A0210. Assessment Reference Date
—
Month

—
Day

Year

A0220. Admission Date
—
Month

—
Day

Year

A0250. Reason for Assessment
Enter Code

1. Admission
4. Admission lasting less than 3 calendar days

A0255. Type of Admission
Enter Code

1. Voluntary
2. Involuntary

A0260. Type of Discharge (Complete only if A0250 = 4)
Enter Code

1. Planned - Following court order
2. Planned - Not following court order
3. Against medical advice (AMA)
4. Unplanned
5. Expired

A0270. Discharge Date (Complete only if A0250 = 4)
—
Month

—
Day

IPF-PAI Admission - Effective 10/01/2027
Centers for Medicare & Medicaid Services

Year

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A0500. Legal Name of Patient
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Medicare Number
B. Medicare Number

A0810. Sex
Enter Code

1. Male
2. Female

A0900. Birth Date
—
Month

—
Day

Year

A1405. Payer Information - Primary Payer
Enter Code

01. Medicare - Part A (traditional fee-for-service)
02. Medicare - Part C (Medicare Advantage)
03. Medicaid fee-for-service
04. Medicaid - other (e.g., managed care)
05. Workers’ compensation
06. Title Programs (e.g., Title III, V, XX)
07. Other government (e.g., TRICARE, VA, etc.)
08. Private insurance - not managed care
09. Private insurance - managed care (e.g., PPO, HMO)
10. Self-pay
98. Other payer
99. Unknown

IPF-PAI Admission - Effective 10/01/2027
Centers for Medicare & Medicaid Services

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Section B

Hearing, Speech, and Vision

B0200. Hearing
Enter Code

Ability to hear (with hearing aid or hearing appliances if normally used)
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

B0600. Speech Clarity
Enter Code

Select best description of speech pattern
0. Clear speech—distinct intelligible words
1. Unclear speech—slurred or mumbled words
2. No speech—absence of spoken words

B1000. Vision
Enter Code

Ability to see in adequate light (with glasses or other visual appliances)
0. Adequate—sees fine detail, such as regular print in newspapers/books
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

Section D

Mood

D1000. Suicide Screening
Enter Code

Has the patient been screened for suicide risk?
1. Yes—using a standardized tool
2. Yes—through clinical assessment
7. Patient declined to respond
9. Patient unable to be assessed

IPF-PAI Admission - Effective 10/01/2027
Centers for Medicare & Medicaid Services

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Section GG Functional Abilities
GG0170. Mobility
For the activity, code the patient’s performance using the 6-point scale. If the activity was not attempted, 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 themself 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
and provides more 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
Enter Codes in Boxes ↓
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or
wheelchair).

Section I

Active Diagnoses

I0060. Indicate the patient’s primary medical condition category
Enter Code

Indicate the patient’s primary medical condition category that best describes the primary reason for admission.
01. Anxiety disorders
02. Delirium, dementia, and amnestic and other cognitive disorders
03. Eating disorders
04. Mood disorders
05. Schizophrenia and other psychotic disorders
06. Substance-related disorders including alcohol-related disorders
09. Other diagnosis—not included in one of the above categories

IPF-PAI Admission - Effective 10/01/2027
Centers for Medicare & Medicaid Services

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Section OO Special Services, Treatments, and Interventions
OO0115. Special Services, Treatments, and Interventions in the Inpatient Psychiatric Setting (Complete only if A0250 = 4)
Indicate all of the following services, treatments, and interventions received during the entire IPF stay.
b. Discharge
Check all that apply
↓
Psychiatric Treatments
A1. Medications
B1. Brain Stimulation
B2. Electroconvulsive Therapy (ECT)
B3. Transcranial Magnetic Stimulation (rTMS)
B4. Other
C1. Non-Pharmacological Treatment (Other than Brain Stimulation)
C2. Therapy (Individual or Group)
C3. Therapeutic Activities
C4. Other
Restrictive Interventions
D1. Seclusion
E1. Restraint
E2. Chemical Restraints
E3. Physical Restraints
E4. Other
F1. Other Interventions
F2. Unit Restrictions
F3. Line of Sight Supervision
F4. 1:1 Observation
F5. Other
None of the Above
Z1. None of the Above

Section Z

Record Administration

Z0510. IPF-PAI Completion Date
This date represents completion of the IPF-PAI for this patient record.
B.

Date
—
Month

IPF-PAI Admission - Effective 10/01/2027
Centers for Medicare & Medicaid Services

—
Day

Year

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