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

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

Discharge assessment period is the last seven (7) calendar days of the IPF stay (includes day of discharge and six [6] calendar days
prior) unless otherwise noted.

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

A0250. Reason for Assessment
Enter Code

9. Discharge

A0260. Type of Discharge
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
—
Month

—
Day

Year

A0500. Legal Name of Patient
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

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

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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

Section D

Mood

D1000. Suicide Screening
Assessment period is the entire IPF stay, excluding the first 3 calendar days of admission.
Enter Code

Section I

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

Active Diagnoses

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

Indicate the patient’s primary medical condition category at discharge.
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 Discharge - 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
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 Discharge - Effective 10/01/2027
Centers for Medicare & Medicaid Services

—
Day

Year

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