IRF-PAI Item Summary

Item

XML Tag

Group

Type

Length

Fixed Start-End

Description

ASMT_SYS_CD ASMT_SYS_CD Control Checklist 10 1-10 Assessment System Code
TRANS_TYPE_CD TRANS_TYPE_CD Control Code 1 11-11 Transaction Type Code
FAC_ID FAC_ID Control Text 10 12-21 Facility ID
STATE_CD STATE_CD Control Code 2 28-29 State Code
FAC_ADDR_1 FAC_ADDR_1 Control Text 30 30-59 Facility Address Line 1
FAC_ADDR_2 FAC_ADDR_2 Control Text 30 60-89 Facility Address Line 2
FAC_CITY FAC_CITY Control Text 20 90-109 Facility City
FAC_ZIP FAC_ZIP Control Text 5 110-114 Facility ZIP Code
FAC_CNTCT FAC_CNTCT Control Text 30 115-144 Facility Contact Person Name
FAC_PHONE FAC_PHONE Control Text 10 145-154 Facility Contact Person Phone
FAC_EXTEN FAC_EXTEN Control Text 5 155-159 Facility Contact Person Phone Extension
FAC_DOC_CD FAC_DOC_CD Control Text 8 160-167 Facility Document ID
ITM_SET_VRSN_CD ITM_SET_VRSN_CD Control Code 5 168-172 IRF-PAI item Set Version
SPEC_VRSN_CD SPEC_VRSN_CD Control Code 5 173-177 Specifications version code
SFTWR_VNDR_ID SFTWR_VNDR_ID Control Text 9 178-186 Software Vendor EIN
SFTWR_VNDR_NAME SFTWR_VNDR_NAME Control Text 30 187-216 Software Vendor Name
SFTWR_VNDR_EMAIL_ADR SFTWR_VNDR_EMAIL_ADR Control Text 50 217-266 Software Vendor Email Address
SFTWR_PROD_NAME SFTWR_PROD_NAME Control Text 50 267-316 Software Product Name
SFTWR_PROD_VRSN_CD SFTWR_PROD_VRSN_CD Control Text 20 317-336 Software Product Version Code
CORRECTION_NUM CORRECTION_NUM Control Number 2 337-338 Correction Number
SBMTD_CMG_TXT SBMTD_CMG_TXT Control Text 10 2128-2137 Submitted CMG Code
SBMTD_CMG_VRSN_TXT SBMTD_CMG_VRSN_TXT Control Text 10 2148-2157 Submitted CMG Version Code
CONTROL_FILLER CNTRL_FLR Control Text 200 339-538 Control items filler
1A R1A Asmt Text 50 539-588 Facility Name
1B R1B Asmt Text 12 589-600 CMS Certification Number (CCN)
2 R2 Asmt Text 12 601-612 Patient Medicare Number
3 R3 Asmt Text 14 613-626 Patient Medicaid Number
4 R4 Asmt Text 12 627-638 Patient First Name
5A R5A Asmt Text 18 639-656 Patient Last Name
6 R6 Asmt Date 8 657-664 Birth Date
7 R7 Asmt Text 9 665-673 Social Security Number (SSN)
8 R8 Asmt Code 1 674-674 Gender
9A R9A Asmt Checklist 1 675-675 Race: American Indian/Alaskan Native
9B R9B Asmt Checklist 1 676-676 Race: Asian
9C R9C Asmt Checklist 1 677-677 Race: Black or African American
9D R9D Asmt Checklist 1 678-678 Ethnicity: Hispanic or Latino
9E R9E Asmt Checklist 1 679-679 Race: Native Hawaiian or other Pacific Islander
9F R9F Asmt Checklist 1 680-680 Race: White
10 R10 Asmt Code 2 681-682 Marital Status
11 R11 Asmt Text 5 683-687 ZIP Code of Patient"s Pre-hospital Residence
12 R12 Asmt Date 8 688-695 Admission Date
13 R13 Asmt Date 8 696-703 Assessment Reference Date
14 R14 Asmt Code 2 704-705 Admission Class
15A R15A Asmt Code 2 1128-1129 Admit From
16A R16A Asmt Code 2 1130-1131 Pre-hospital Living Setting
17 R17 Asmt Code 2 710-711 Pre-Hospital Living With
20A R20A Asmt Code 2 716-717 Primary Payment Source
20B R20B Asmt Code 2 718-719 Secondary Payment Source
21A R21A Asmt Code 9 720-728 Impairment Group: Admission
21D R21D Asmt Code 9 729-737 Impairment Group: Discharge
22A R22A Asmt ICD 8 1426-1433 Etiologic Diagnosis Code A (ICD Code)
22B R22B Asmt ICD 8 1313-1320 Etiologic Diagnosis Code B (ICD Code)
22C R22C Asmt ICD 8 1321-1328 Etiologic Diagnosis Code C (ICD Code)
23 R23 Asmt Date 8 746-753 Date of Onset
24A R24A Asmt ICD 8 754-761 Comorbid Condition 1 (ICD Code)
24B R24B Asmt ICD 8 762-769 Comorbid Condition 2 (ICD Code)
24C R24C Asmt ICD 8 770-777 Comorbid Condition 3 (ICD Code)
24D R24D Asmt ICD 8 778-785 Comorbid Condition 4 (ICD Code)
24E R24E Asmt ICD 8 786-793 Comorbid Condition 5 (ICD Code)
24F R24F Asmt ICD 8 794-801 Comorbid Condition 6 (ICD Code)
24G R24G Asmt ICD 8 802-809 Comorbid Condition 7 (ICD Code)
24H R24H Asmt ICD 8 810-817 Comorbid Condition 8 (ICD Code)
24I R24I Asmt ICD 8 818-825 Comorbid Condition 9 (ICD Code)
24J R24J Asmt ICD 8 826-833 Comorbid Condition 10 (ICD Code)
24K R24K Asmt ICD 8 1132-1139 Comorbid Condition 11 (ICD Code)
24L R24L Asmt ICD 8 1140-1147 Comorbid Condition 12 (ICD Code)
24M R24M Asmt ICD 8 1148-1155 Comorbid Condition 13 (ICD Code)
24N R24N Asmt ICD 8 1156-1163 Comorbid Condition 14 (ICD Code)
24O R24O Asmt ICD 8 1164-1171 Comorbid Condition 15 (ICD Code)
24P R24P Asmt ICD 8 1172-1179 Comorbid Condition 16 (ICD Code)
24Q R24Q Asmt ICD 8 1180-1187 Comorbid Condition 17 (ICD Code)
24R R24R Asmt ICD 8 1188-1195 Comorbid Condition 18 (ICD Code)
24S R24S Asmt ICD 8 1196-1203 Comorbid Condition 19 (ICD Code)
24T R24T Asmt ICD 8 1204-1211 Comorbid Condition 20 (ICD Code)
24U R24U Asmt ICD 8 1212-1219 Comorbid Condition 21 (ICD Code)
24V R24V Asmt ICD 8 1220-1227 Comorbid Condition 22 (ICD Code)
24W R24W Asmt ICD 8 1228-1235 Comorbid Condition 23 (ICD Code)
24X R24X Asmt ICD 8 1236-1243 Comorbid Condition 24 (ICD Code)
24Y R24Y Asmt ICD 8 1244-1251 Comorbid Condition 25 (ICD Code)
24A1 R24A1 Asmt Code 1 1329-1329 Arthritis Conditions Recorded
25A R25A Asmt Number 2 1252-1253 Height
26A R26A Asmt Number 3 1254-1256 Weight
27A R27A Asmt Code 2 836-837 Swallowing Status: Admission
27D R27D Asmt Code 2 838-839 Swallowing Status: Discharge
29A R29A Asmt Code 2 842-843 Bladder Level of Assistance: Admission
29D R29D Asmt Code 2 844-845 Bladder Level of Assistance: Discharge
30A R30A Asmt Code 2 846-847 Bladder Frequency of Accidents: Admission
30D R30D Asmt Code 2 848-849 Bladder Frequency of Accidents: Discharge
31A R31A Asmt Code 2 850-851 Bowel Level of Assistance: Admission
31D R31D Asmt Code 2 852-853 Bowel Level of Assistance: Discharge
32A R32A Asmt Code 2 854-855 Bowel Frequency of Accidents: Admission
32D R32D Asmt Code 2 856-857 Bowel Frequency of Accidents: Discharge
33A R33A Asmt Code 2 858-859 Tub Transfer: Admission
33D R33D Asmt Code 2 860-861 Tub Transfer: Discharge
34A R34A Asmt Code 2 862-863 Shower Transfer: Admission
34D R34D Asmt Code 2 864-865 Shower Transfer: Discharge
35A R35A Asmt Code 2 866-867 Distance Walked: Admission
35D R35D Asmt Code 2 868-869 Distance Walked: Discharge
36A R36A Asmt Code 2 870-871 Distance Traveled in Wheelchair: Admission
36D R36D Asmt Code 2 872-873 Distance Traveled in Wheelchair: Discharge
37A R37A Asmt Code 2 874-875 Walk: Admission
37D R37D Asmt Code 2 876-877 Walk: Discharge
38A R38A Asmt Code 2 878-879 Wheelchair: Admission
38D R38D Asmt Code 2 880-881 Wheelchair: Discharge
39AA R39AA Asmt Code 2 882-883 Self-Care -Eating: Admission
39AD R39AD Asmt Code 2 884-885 Self-Care -Eating: Discharge
39AG R39AG Asmt Code 2 886-887 Self-Care -Eating: Goal
39BA R39BA Asmt Code 2 888-889 Self-Care -Grooming: Admission
39BD R39BD Asmt Code 2 890-891 Self-Care -Grooming: Discharge
39BG R39BG Asmt Code 2 892-893 Self-Care -Grooming: Goal
39CA R39CA Asmt Code 2 894-895 Self-Care -Bathing: Admission
39CD R39CD Asmt Code 2 896-897 Self-Care -Bathing: Discharge
39CG R39CG Asmt Code 2 898-899 Self-Care -Bathing: Goal
39DA R39DA Asmt Code 2 900-901 Self-Care -Dressing - Upper: Admission
39DD R39DD Asmt Code 2 902-903 Self-Care -Dressing - Upper: Discharge
39DG R39DG Asmt Code 2 904-905 Self-Care -Dressing - Upper: Goal
39EA R39EA Asmt Code 2 906-907 Self-Care -Dressing - Lower: Admission
39ED R39ED Asmt Code 2 908-909 Self-Care -Dressing - Lower: Discharge
39EG R39EG Asmt Code 2 910-911 Self-Care -Dressing - Lower: Goal
39FA R39FA Asmt Code 2 912-913 Self-Care -Toileting: Admission
39FD R39FD Asmt Code 2 914-915 Self-Care -Toileting: Discharge
39FG R39FG Asmt Code 2 916-917 Self-Care -Toileting: Goal
39GA R39GA Asmt Code 2 918-919 Sphincter Control -Bladder: Admission
39GD R39GD Asmt Code 2 920-921 Sphincter Control -Bladder: Discharge
39GG R39GG Asmt Code 2 922-923 Sphincter Control -Bladder: Goal
39HA R39HA Asmt Code 2 924-925 Sphincter Control -Bowel: Admission
39HD R39HD Asmt Code 2 926-927 Sphincter Control -Bowel: Discharge
39HG R39HG Asmt Code 2 928-929 Sphincter Control -Bowel: Goal
39IA R39IA Asmt Code 2 930-931 Transfers -Bed, Chair, Wheelchair: Admission
39ID R39ID Asmt Code 2 932-933 Transfers -Bed, Chair, Wheelchair: Discharge
39IG R39IG Asmt Code 2 934-935 Transfers -Bed, Chair, Wheelchair: Goal
39JA R39JA Asmt Code 2 936-937 Transfers -Toilet: Admission
39JD R39JD Asmt Code 2 938-939 Transfers -Toilet: Discharge
39JG R39JG Asmt Code 2 940-941 Transfers -Toilet: Goal
39KA R39KA Asmt Code 2 942-943 Transfers -Tub, Shower: Admission
39KD R39KD Asmt Code 2 944-945 Transfers - Tub, Shower: Discharge
39KG R39KG Asmt Code 2 946-947 Transfers -Tub, Shower: Goal
39LA R39LA Asmt Code 2 948-949 Locomotion -Walk/Wheelchair: Admission
39LAA R39LAA Asmt Code 1 950-950 Locomotion -Walk/Wheelchair/both: Admission
39LD R39LD Asmt Code 2 951-952 Locomotion -Walk/Wheelchair: Discharge
39LDD R39LDD Asmt Code 1 953-953 Locomotion -Walk/Wheelchair/both: Discharge
39LG R39LG Asmt Code 2 954-955 Locomotion -Walk/Wheelchair: Goal
39MA R39MA Asmt Code 2 956-957 Locomotion -Stairs: Admission
39MD R39MD Asmt Code 2 958-959 Locomotion -Stairs: Discharge
39MG R39MG Asmt Code 2 960-961 Locomotion -Stairs: Goal
39NA R39NA Asmt Code 2 962-963 Communication -Comprehension: Admission
39NAA R39NAA Asmt Code 1 964-964 Communication -Comp Auditory/Visual/Both:Admission
39ND R39ND Asmt Code 2 965-966 Communication -Comprehension: Discharge
39NDD R39NDD Asmt Code 1 967-967 Communication -Comp Auditory/Visual/Both:Discharge
39NG R39NG Asmt Code 2 968-969 Communication -Comprehension: Goal
39OA R39OA Asmt Code 2 970-971 Communication -Expression: Admission
39OAA R39OAA Asmt Code 1 972-972 Communication -Expr Vocal/Nonvocal/Both: Admission
39OD R39OD Asmt Code 2 973-974 Communication -Expression: Discharge
39ODD R39ODD Asmt Code 1 975-975 Communication -Expr Vocal/Nonvocal/Both: Discharge
39OG R39OG Asmt Code 2 976-977 Communication -Expression: Goal
39PA R39PA Asmt Code 2 978-979 Social Cognition -Social Interaction: Admission
39PD R39PD Asmt Code 2 980-981 Social Cognition -Social Interaction: Discharge
39PG R39PG Asmt Code 2 982-983 Social Cognition -Social Interaction: Goal
39QA R39QA Asmt Code 2 984-985 Social Cognition -Problem Solving: Admission
39QD R39QD Asmt Code 2 986-987 Social Cognition -Problem Solving: Discharge
39QG R39QG Asmt Code 2 988-989 Social Cognition -Problem Solving: Goal
39RA R39RA Asmt Code 2 990-991 Social Cognition -Memory: Admission
39RD R39RD Asmt Code 2 992-993 Social Cognition -Memory: Discharge
39RG R39RG Asmt Code 2 994-995 Social Cognition -Memory: Goal
40 R40 Asmt Date 8 996-1003 Discharge Date
41 R41 Asmt Code 1 1004-1004 Patient Discharged Against Medical Advice
42 R42 Asmt Code 1 1005-1005 Program Interruption(s) Indicator
43A R43A Asmt Date 8 1006-1013 1st Interruption Date
43B R43B Asmt Date 8 1014-1021 1st Return Date
43C R43C Asmt Date 8 1022-1029 2nd Interruption Date
43D R43D Asmt Date 8 1030-1037 2nd Return Date
43E R43E Asmt Date 8 1038-1045 3rd Interruption Date
43F R43F Asmt Date 8 1046-1053 3rd Return Date
44C R44C Asmt Code 1 1257-1257 Patient Discharged Alive
44D R44D Asmt Code 2 1259-1260 Discharge to Living Setting
45 R45 Asmt Code 2 1057-1058 Discharge to Living With
46 R46 Asmt ICD 8 1059-1066 Diagnosis for Interruption or Death (ICD Code)
47A R47A Asmt ICD 8 1067-1074 Complication during rehab stay 1 (ICD Code)
47B R47B Asmt ICD 8 1075-1082 Complication during rehab stay 2 (ICD Code)
47C R47C Asmt ICD 8 1083-1090 Complication during rehab stay 3 (ICD Code)
47D R47D Asmt ICD 8 1091-1098 Complication during rehab stay 4 (ICD Code)
47E R47E Asmt ICD 8 1099-1106 Complication during rehab stay 5 (ICD Code)
47F R47F Asmt ICD 8 1107-1114 Complication during rehab stay 6 (ICD Code)
O0401AA O0401AA Asmt Number 4 1330-1333 Physical Therapy - Individual Minutes Week 1
O0401AB O0401AB Asmt Number 4 1334-1337 Physical Therapy - Concurrent Minutes Week 1
O0401AC O0401AC Asmt Number 4 1338-1341 Physical Therapy - Group Minutes Week 1
O0401AD O0401AD Asmt Number 4 1342-1345 Physical Therapy - Co-treatment Minutes Week 1
O0401BA O0401BA Asmt Number 4 1346-1349 Occupational Therapy - Individual Minutes Week 1
O0401BB O0401BB Asmt Number 4 1350-1353 Occupational Therapy - Concurrent Minutes Week 1
O0401BC O0401BC Asmt Number 4 1354-1357 Occupational Therapy - Group Minutes Week 1
O0401BD O0401BD Asmt Number 4 1358-1361 Occupational Therapy - Co-treatment Minutes Week 1
O0401CA O0401CA Asmt Number 4 1362-1365 SLP Therapy - Individual Minutes Week 1
O0401CB O0401CB Asmt Number 4 1366-1369 SLP Therapy - Concurrent Minutes Week 1
O0401CC O0401CC Asmt Number 4 1370-1373 SLP Therapy - Group Minutes Week 1
O0401CD O0401CD Asmt Number 4 1374-1377 SLP Therapy - Co-treatment Minutes Week 1
O0402AA O0402AA Asmt Number 4 1378-1381 Physical Therapy - Individual Minutes Week 2
O0402AB O0402AB Asmt Number 4 1382-1385 Physical Therapy - Concurrent Minutes Week 2
O0402AC O0402AC Asmt Number 4 1386-1389 Physical Therapy - Group Minutes Week 2
O0402AD O0402AD Asmt Number 4 1390-1393 Physical Therapy - Co-treatment Minutes Week 2
O0402BA O0402BA Asmt Number 4 1394-1397 Occupational Therapy - Individual Minutes Week 2
O0402BB O0402BB Asmt Number 4 1398-1401 Occupational Therapy - Concurrent Minutes Week 2
O0402BC O0402BC Asmt Number 4 1402-1405 Occupational Therapy - Group Minutes Week 2
O0402BD O0402BD Asmt Number 4 1406-1409 Occupational Therapy - Co-treatment Minutes Week 2
O0402CA O0402CA Asmt Number 4 1410-1413 SLP Therapy - Individual Minutes Week 2
O0402CB O0402CB Asmt Number 4 1414-1417 SLP Therapy - Concurrent Minutes Week 2
O0402CC O0402CC Asmt Number 4 1418-1421 SLP Therapy - Group Minutes Week 2
O0402CD O0402CD Asmt Number 4 1422-1425 SLP Therapy - Co-treatment Minutes Week 2
BB0700 BB0700 Asmt Code 1 1434-1434 Expression of Ideas and Wants (3-day asmt period)
BB0800 BB0800 Asmt Code 1 1435-1435 Understanding Verbal Content (3-day asmt period)
C0100 C0100 Asmt Code 1 1436-1436 Brief Interview - Mental Status (BIMS)
C0200 C0200 Asmt Code 1 1437-1437 BIMS - Repetition of Three Words
C0300A C0300A Asmt Code 1 1438-1438 BIMS - Temporal Orientation - Year
C0300B C0300B Asmt Code 1 1439-1439 BIMS - Temporal Orientation - Month
C0300C C0300C Asmt Code 1 1440-1440 BIMS - Temporal Orientation - Day
C0400A C0400A Asmt Code 1 1441-1441 BIMS - Recalls Sock
C0400B C0400B Asmt Code 1 1442-1442 BIMS - Recalls Blue
C0400C C0400C Asmt Code 1 1443-1443 BIMS - Recalls Bed
C0500 C0500 Asmt Number 2 1444-1445 BIMS - Summary Score
C0600 C0600 Asmt Code 1 1446-1446 Conduct Staff Assessment - Mental Status
C0900A C0900A Asmt Checklist 1 1447-1447 Memory/Recall Ability - Current Season
C0900B C0900B Asmt Checklist 1 1448-1448 Memory/Recall Ability - Location Of Own Room
C0900C C0900C Asmt Checklist 1 1449-1449 Memory/Recall Ability - Staff Names and Faces
C0900E C0900E Asmt Checklist 1 1450-1450 Memory/Recall Ability - In Hospital unit
C0900Z C0900Z Asmt Checklist 1 1451-1451 Memory/Recall Ability - None Of The Above
GG0100A GG0100A Asmt Code 1 1452-1452 Prior Function - Self Care
GG0100B GG0100B Asmt Code 1 1453-1453 Prior Function - Indoor Mobility (Ambulation)
GG0100C GG0100C Asmt Code 1 1454-1454 Prior Function - Stairs
GG0100D GG0100D Asmt Code 1 1455-1455 Prior Function - Functional Cognition
GG0110A GG0110A Asmt Checklist 1 1456-1456 Prior Device - Manual wheelchair
GG0110B GG0110B Asmt Checklist 1 1457-1457 Prior Device - Motorized wheelchair or scooter
GG0110C GG0110C Asmt Checklist 1 1458-1458 Prior Device - Mechanical lift
GG0110D GG0110D Asmt Checklist 1 1459-1459 Prior Device - Walker
GG0110E GG0110E Asmt Checklist 1 1460-1460 Prior Device - Orthotics/Prosthetics
GG0110Z GG0110Z Asmt Checklist 1 1461-1461 Prior Device - None of the above
GG0130A1 GG0130A1 Asmt Code 2 1462-1463 Self-Care (Adm Perf) - Eating
GG0130A2 GG0130A2 Asmt Code 2 1464-1465 Self-Care (Dschg Goal) - Eating
GG0130A3 GG0130A3 Asmt Code 2 1466-1467 Self-Care (Dschg Perf) - Eating
GG0130B1 GG0130B1 Asmt Code 2 1468-1469 Self-Care (Adm Perf) - Oral hygiene
GG0130B2 GG0130B2 Asmt Code 2 1470-1471 Self-Care (Dschg Goal) - Oral hygiene
GG0130B3 GG0130B3 Asmt Code 2 1472-1473 Self-Care (Dschg Perf) - Oral hygiene
GG0130C1 GG0130C1 Asmt Code 2 1474-1475 Self-Care (Adm Perf) - Toileting hygiene
GG0130C2 GG0130C2 Asmt Code 2 1476-1477 Self-Care (Dschg Goal) - Toileting hygiene
GG0130C3 GG0130C3 Asmt Code 2 1478-1479 Self-Care (Dschg Perf) - Toileting hygiene
GG0130E1 GG0130E1 Asmt Code 2 1480-1481 Self-Care (Adm Perf) - Shower/bathe self
GG0130E2 GG0130E2 Asmt Code 2 1482-1483 Self-Care (Dschg Goal) - Shower/bathe self
GG0130E3 GG0130E3 Asmt Code 2 1484-1485 Self-Care (Dschg Perf) - Shower/bathe self
GG0130F1 GG0130F1 Asmt Code 2 1486-1487 Self-Care (Adm Perf) - Upper Body Dressing
GG0130F2 GG0130F2 Asmt Code 2 1488-1489 Self-Care (Dschg Goal) - Upper Body Dressing
GG0130F3 GG0130F3 Asmt Code 2 1490-1491 Self-Care (Dschg Perf) - Upper Body Dressing
GG0130G1 GG0130G1 Asmt Code 2 1492-1493 Self-Care (Adm Perf) - Lower Body Dressing
GG0130G2 GG0130G2 Asmt Code 2 1494-1495 Self-Care (Dschg Goal) - Lower Body Dressing
GG0130G3 GG0130G3 Asmt Code 2 1496-1497 Self-Care (Dschg Perf) - Lower Body Dressing
GG0130H1 GG0130H1 Asmt Code 2 1498-1499 Self-Care (Adm Perf) - On/Off Footwear
GG0130H2 GG0130H2 Asmt Code 2 1500-1501 Self-Care (Dschg Goal) - On/Off Footwear
GG0130H3 GG0130H3 Asmt Code 2 1502-1503 Self-Care (Dschg Perf) - On/Off Footwear
GG0170A1 GG0170A1 Asmt Code 2 1504-1505 Func Mobil (Adm Perf) - Roll left and right
GG0170A2 GG0170A2 Asmt Code 2 1506-1507 Func Mobil (Dschg Goal) - Roll left and right
GG0170A3 GG0170A3 Asmt Code 2 1508-1509 Func Mobil (Dschg Perf) - Roll left and right
GG0170B1 GG0170B1 Asmt Code 2 1510-1511 Func Mobil (Adm Perf) - Sit to lying
GG0170B2 GG0170B2 Asmt Code 2 1512-1513 Func Mobil (Dschg Goal) - Sit to lying
GG0170B3 GG0170B3 Asmt Code 2 1514-1515 Func Mobil (Dschg Perf) - Sit to lying
GG0170C1 GG0170C1 Asmt Code 2 1516-1517 Func Mobil (Adm Perf) - Lying to sit on side
GG0170C2 GG0170C2 Asmt Code 2 1518-1519 Func Mobil (Dschg Goal) - Lying to sitting on side
GG0170C3 GG0170C3 Asmt Code 2 1520-1521 Func Mobil (Dschg Perf) - Lying to sitting on side
GG0170D1 GG0170D1 Asmt Code 2 1522-1523 Func Mobil (Adm Perf) - Sit to stand
GG0170D2 GG0170D2 Asmt Code 2 1524-1525 Func Mobil (Dschg Goal) - Sit to stand
GG0170D3 GG0170D3 Asmt Code 2 1526-1527 Func Mobil (Dschg Perf) - Sit to stand
GG0170E1 GG0170E1 Asmt Code 2 1528-1529 Func Mobil (Adm Perf) - Chair/bed-to-chair trans
GG0170E2 GG0170E2 Asmt Code 2 1530-1531 Func Mobil (Dschg Goal) - Chair/bed-to-chair trans
GG0170E3 GG0170E3 Asmt Code 2 1532-1533 Func Mobil (Dschg Perf) - Chair/bed-to-chair trans
GG0170F1 GG0170F1 Asmt Code 2 1534-1535 Func Mobil (Adm Perf) - Toilet transfer
GG0170F2 GG0170F2 Asmt Code 2 1536-1537 Func Mobil (Dschg Goal) - Toilet transfer
GG0170F3 GG0170F3 Asmt Code 2 1538-1539 Func Mobil (Dschg Perf) - Toilet transfer
GG0170G1 GG0170G1 Asmt Code 2 1540-1541 Func Mobil (Adm Perf) - Car Transfer
GG0170G2 GG0170G2 Asmt Code 2 1542-1543 Func Mobil (Dschg Goal) - Car Transfer
GG0170G3 GG0170G3 Asmt Code 2 1544-1545 Func Mobil (Dschg Perf) - Car Transfer
GG0170H1 GG0170H1 Asmt Code 1 1546-1546 Does the patient walk (Adm)
GG0170H3 GG0170H3 Asmt Code 1 1547-1547 Does the patient walk (Dschg)
GG0170I1 GG0170I1 Asmt Code 2 1548-1549 Func Mobil (Adm Perf) - Walk 10 feet
GG0170I2 GG0170I2 Asmt Code 2 1550-1551 Func Mobil (Dschg Goal) - Walk 10 feet
GG0170I3 GG0170I3 Asmt Code 2 1552-1553 Func Mobil (Dschg Perf) - Walk 10 feet
GG0170J1 GG0170J1 Asmt Code 2 1554-1555 Func Mobil (Adm Perf) - Walk 50 feet w/2 turns
GG0170J2 GG0170J2 Asmt Code 2 1556-1557 Func Mobil (Dschg Goal) - Walk 50 feet w/2 turns
GG0170J3 GG0170J3 Asmt Code 2 1558-1559 Func Mobil (Dschg Perf) - Walk 50 feet w/2 turns
GG0170K1 GG0170K1 Asmt Code 2 1560-1561 Func Mobil (Adm Perf) - Walk 150 feet
GG0170K2 GG0170K2 Asmt Code 2 1562-1563 Func Mobil (Dschg Goal) - Walk 150 feet
GG0170K3 GG0170K3 Asmt Code 2 1564-1565 Func Mobil (Dschg Perf) - Walk 150 feet
GG0170L1 GG0170L1 Asmt Code 2 1566-1567 Func Mobil (Adm Perf) - Walk 10 Ft Uneven Surf
GG0170L2 GG0170L2 Asmt Code 2 1568-1569 Func Mobil (Dschg Goal) - Walk 10 Ft Uneven Surf
GG0170L3 GG0170L3 Asmt Code 2 1570-1571 Func Mobil (Dschg Perf) - Walk 10 Ft Uneven Surf
GG0170M1 GG0170M1 Asmt Code 2 1572-1573 Func Mobil (Adm Perf) - 1 Step (Curb)
GG0170M2 GG0170M2 Asmt Code 2 1574-1575 Func Mobil (Dschg Goal) - 1 Step (Curb)
GG0170M3 GG0170M3 Asmt Code 2 1576-1577 Func Mobil (Dschg Perf) - 1 Step (Curb)
GG0170N1 GG0170N1 Asmt Code 2 1578-1579 Func Mobil (Adm Perf) - 4 Steps
GG0170N2 GG0170N2 Asmt Code 2 1580-1581 Func Mobil (Dschg Goal) - 4 Steps
GG0170N3 GG0170N3 Asmt Code 2 1582-1583 Func Mobil (Dschg Perf) - 4 Steps
GG0170O1 GG0170O1 Asmt Code 2 1584-1585 Func Mobil (Adm Perf) - 12 Steps
GG0170O2 GG0170O2 Asmt Code 2 1586-1587 Func Mobil (Dschg Goal) - 12 Steps
GG0170O3 GG0170O3 Asmt Code 2 1588-1589 Func Mobil (Dschg Perf) - 12 Steps
GG0170P1 GG0170P1 Asmt Code 2 1590-1591 Func Mobil (Adm Perf) - Picking Up Object
GG0170P2 GG0170P2 Asmt Code 2 1592-1593 Func Mobil (Dschg Goal) - Picking Up Object
GG0170P3 GG0170P3 Asmt Code 2 1594-1595 Func Mobil (Dschg Perf) - Picking Up Object
GG0170Q1 GG0170Q1 Asmt Code 1 1596-1596 Does the patient use a wheelchair/scooter (Adm)
GG0170Q3 GG0170Q3 Asmt Code 1 1597-1597 Does the patient use a wheelchair/scooter (Dschg)
GG0170R1 GG0170R1 Asmt Code 2 1598-1599 Func Mobil (Adm Perf) - Wheel 50 feet w/2 turns
GG0170R2 GG0170R2 Asmt Code 2 1600-1601 Func Mobil (Dschg Goal) - Wheel 50 feet w/2 turns
GG0170R3 GG0170R3 Asmt Code 2 1602-1603 Func Mobil (Dschg Perf) - Wheel 50 feet w/2 turns
GG0170RR1 GG0170RR1 Asmt Code 1 1604-1604 Indicate the type of wheelchair/scooter (Adm)
GG0170RR3 GG0170RR3 Asmt Code 1 1605-1605 Indicate the type of wheelchair/scooter (Dschg)
GG0170S1 GG0170S1 Asmt Code 2 1606-1607 Func Mobil (Adm Perf) - Wheel 150 feet
GG0170S2 GG0170S2 Asmt Code 2 1608-1609 Func Mobil (Dschg Goal) - Wheel 150 feet
GG0170S3 GG0170S3 Asmt Code 2 1610-1611 Func Mobil (Dschg Perf) - Wheel 150 feet
GG0170SS1 GG0170SS1 Asmt Code 1 1612-1612 Indicate the type of wheelchair/scooter (Adm)
GG0170SS3 GG0170SS3 Asmt Code 1 1613-1613 Indicate the type of wheelchair/scooter (Dschg)
H0350 H0350 Asmt Code 1 1614-1614 Bladder continence
H0400 H0400 Asmt Code 1 1615-1615 Bowel continence
I0900 I0900 Asmt Checklist 1 1616-1616 Diagnoses: Peripheral vascular disease (PVD)/PAD
I2900 I2900 Asmt Checklist 1 1617-1617 Diagnoses: Diabetes mellitus (DM)
I7900 I7900 Asmt Checklist 1 1618-1618 Diagnoses: None of the Above
J1750 J1750 Asmt Code 1 1619-1619 History Of Falls
J1800 J1800 Asmt Code 1 1620-1620 Any Falls Since Admission
J1900A J1900A Asmt Code 1 1621-1621 Num Falls Since Admission - No injury
J1900B J1900B Asmt Code 1 1622-1622 Num Falls Since Admission - Injury (except major)
J1900C J1900C Asmt Code 1 1623-1623 Num Falls Since Admission - Major injury
J2000 J2000 Asmt Code 1 1624-1624 Prior Surgery
K0110A K0110A Asmt Checklist 1 1625-1625 Swallow/Nutrit - Regular Food
K0110B K0110B Asmt Checklist 1 1626-1626 Swallow/Nutrit - Modified Food
K0110C K0110C Asmt Checklist 1 1627-1627 Swallow/Nutrit - Tube/Parenteral Feeding
M0210_1 M0210_1 Asmt Code 1 1261-1261 Pressure Ulcers Present on Admission
M0210_2 M0210_2 Asmt Code 1 1262-1262 Pressure Ulcers Present on Discharge
M0300A1_1 M0300A1_1 Asmt Number 1 1263-1263 Number of Stage 1 pressure ulcers: Admission
M0300A1_2 M0300A1_2 Asmt Number 1 1264-1264 Number of Stage 1 pressure ulcers: Discharge
M0300B1_1 M0300B1_1 Asmt Number 1 1267-1267 Number of Stage 2 pressure ulcers: Admission
M0300B1_2 M0300B1_2 Asmt Number 1 1268-1268 Number of Stage 2 pressure ulcers: Discharge
M0300B2_2 M0300B2_2 Asmt Number 1 1269-1269 Nbr Disch Stg 2 PU were Adm Stg 2 PU
M0300C1_1 M0300C1_1 Asmt Number 1 1272-1272 Number of Stage 3 pressure ulcers: Admission
M0300C1_2 M0300C1_2 Asmt Number 1 1273-1273 Number of Stage 3 pressure ulcers: Discharge
M0300C2_2 M0300C2_2 Asmt Number 1 1274-1274 Nbr Disch Stg 3 PU were Adm Stg 3 PU
M0300D1_1 M0300D1_1 Asmt Number 1 1277-1277 Number of Stage 4 pressure ulcers: Admission
M0300D1_2 M0300D1_2 Asmt Number 1 1278-1278 Number of Stage 4 pressure ulcers: Discharge
M0300D2_2 M0300D2_2 Asmt Number 1 1279-1279 Nbr Disch Stg 4 PU were Adm Stg 4 PU
M0300E1_1 M0300E1_1 Asmt Number 1 1282-1282 Nbr Unstg non-remov drsg pressure ulcers: Adm
M0300E1_2 M0300E1_2 Asmt Number 1 1283-1283 Nbr Unstg non-remov drsg pressure ulcers: Dschrg
M0300E2_2 M0300E2_2 Asmt Number 1 1284-1284 Nbr Unstg NRD Disch PU were Adm Unstg NRD PU
M0300F1_1 M0300F1_1 Asmt Number 1 1286-1286 Nbr Unstg slough/eschar pressure ulcers: Adm
M0300F1_2 M0300F1_2 Asmt Number 1 1287-1287 Nbr Unstg slough/eschar pressure ulcers: Dschrg
M0300F2_2 M0300F2_2 Asmt Number 1 1288-1288 Nbr Unstg S/E Disch PU were Adm Unstg S/E PU
M0300G1_1 M0300G1_1 Asmt Number 1 1290-1290 Nbr Unstg DTI pressure ulcers: Adm
M0300G1_2 M0300G1_2 Asmt Number 1 1291-1291 Nbr Unstg DTI pressure ulcers: Dschrg
M0300G2_2 M0300G2_2 Asmt Number 1 1292-1292 Nbr Unstg DTI Disch PU were Adm Unstg DTI PU
M0800A M0800A Asmt Number 1 1628-1628 Worsened: Stage 2 pressure ulcers
M0800B M0800B Asmt Number 1 1629-1629 Worsened: Stage 3 pressure ulcers
M0800C M0800C Asmt Number 1 1630-1630 Worsened: Stage 4 pressure ulcers
M0800D M0800D Asmt Number 1 1631-1631 Worsened: Unstageable - Non-removable dressing
M0800E M0800E Asmt Number 1 1632-1632 Worsened: Unstageable - Slough and/or eschar
M0800F M0800F Asmt Number 1 1633-1633 Worsened: Unstageable - Deep tissue injury
M0900A1 M0900A1 Asmt Number 1 1293-1293 Number of Stage 1 Healed Pressure Ulcers
M0900B M0900B Asmt Number 1 1294-1294 Number of Stage 2 Healed Pressure Ulcers
M0900C M0900C Asmt Number 1 1295-1295 Number of Stage 3 Healed Pressure Ulcers
M0900D M0900D Asmt Number 1 1296-1296 Number of Stage 4 Healed Pressure Ulcers
O0100N O0100N Asmt Checklist 1 1634-1634 Total Parenteral Nutrition
O0250A O0250A Asmt Code 1 1303-1303 Was influenza vaccine received
O0250B O0250B Asmt Date 8 1304-1311 Date influenza vaccine received
O0250C O0250C Asmt Code 1 1312-1312 If influenza vaccine not received, state reason
Filler - 15 FILLER_15 Filler Text 2 706-707 Prior v1.10 Admit From
Filler - 16 FILLER_16 Filler Text 2 708-709 Prior v1.10 Pre-Hospital Living Setting
Filler - 18 FILLER_18 Filler Text 2 712-713 Prior v1.10 Pre-Hospital Vocational Category
Filler - 19 FILLER_19 Filler Text 2 714-715 Prior v1.10 Pre-Hospital Vocational Effort
Filler - 22 FILLER_22 Filler Text 8 738-745 Prior V1.11 Etiologic Diagnosis Code A (ICD Code)
Filler - 25 FILLER_25 Filler Text 1 834-834 Prior v1.10 Comatose: Admission
Filler - 26 FILLER_26 Filler Text 1 835-835 Prior v1.10 Delirious: Admission
Filler - 28A FILLER_28A Filler Text 1 840-840 Prior v1.10 Clinical Signs of Dehydration: Adm
Filler - 28D FILLER_28D Filler Text 1 841-841 Prior v1.10 Clinical Signs of Dehydration: Disch
Filler - 44A FILLER_44A Filler Text 2 1054-1055 Prior v1.10 Discharge to Living Setting
Filler - 44B FILLER_44B Filler Text 1 1056-1056 Prior v1.10 Patient Dschrgd with HH Services
Filler - 48AA FILLER_48AA Filler Text 1 1115-1115 Filler for deleted item
Filler - 48AD FILLER_48AD Filler Text 1 1116-1116 Filler for deleted item
Filler - 48BA FILLER_48BA Filler Text 1 1117-1117 Filler for deleted item
Filler - 48BD FILLER_48BD Filler Text 1 1118-1118 Filler for deleted item
Filler - 48CA FILLER_48CA Filler Text 1 1119-1119 Filler for deleted item
Filler - 48CD FILLER_48CD Filler Text 1 1120-1120 Filler for deleted item
Filler - 49A FILLER_49A Filler Text 1 1121-1121 Filler for deleted item
Filler - 49B FILLER_49B Filler Text 1 1122-1122 Filler for deleted item
Filler - 49C FILLER_49C Filler Text 1 1123-1123 Filler for deleted item
Filler - 50A FILLER_50A Filler Text 1 1124-1124 Filler for deleted item
Filler - 50B FILLER_50B Filler Text 1 1125-1125 Filler for deleted item
Filler - 50C FILLER_50C Filler Text 1 1126-1126 Filler for deleted item
Filler - 50D FILLER_50D Filler Text 1 1127-1127 Filler for deleted item
FILLER-44C_LNGTH FILLER_44C_LNGTH Filler Text 1 1258-1258 Filler for reduced length
Filler - FAC_ID_LNGTH FILLER_FAC_ID_LNGTH Filler Text 6 22-27 Filler for the excess length trimmed from FAC_ID
FILLER - I0900A FILLER_I0900A Filler Text 1 1297-1297 Filler for deleted item
FILLER - I0900B FILLER_I0900B Filler Text 1 1298-1298 Filler for deleted item
FILLER - I2900A FILLER_I2900A Filler Text 1 1299-1299 Filler for deleted item
FILLER - I2900B FILLER_I2900B Filler Text 1 1300-1300 Filler for deleted item
FILLER - I2900C FILLER_I2900C Filler Text 1 1301-1301 Filler for deleted item
FILLER - I2900D FILLER_I2900D Filler Text 1 1302-1302 Filler for deleted item
FILLER - M0300A2_2 FILLER_M0300A2_2 Filler Text 1 1265-1265 Filler for deleted item
FILLER - M0300A3_2 FILLER_M0300A3_2 Filler Text 1 1266-1266 Filler for deleted item
FILLER - M0300B3_2 FILLER_M0300B3_2 Filler Text 1 1270-1270 Filler for deleted item
FILLER - M0300B4_2 FILLER_M0300B4_2 Filler Text 1 1271-1271 Filler for deleted item
FILLER - M0300C3_2 FILLER_M0300C3_2 Filler Text 1 1275-1275 Filler for deleted item
FILLER - M0300C4_2 FILLER_M0300C4_2 Filler Text 1 1276-1276 Filler for deleted item
FILLER - M0300D3_2 FILLER_M0300D3_2 Filler Text 1 1280-1280 Filler for deleted item
FILLER - M0300D4_2 FILLER_M0300D4_2 Filler Text 1 1281-1281 Filler for deleted item
FILLER - M0300E3_2 FILLER_M0300E3_2 Filler Text 1 1285-1285 Filler for deleted item
FILLER - M0300F3_2 FILLER_M0300F3_2 Filler Text 1 1289-1289 Filler for deleted item
ASMT_FILLER ASMT_FILLER Asmt Text 493 1635-2127 Assessment items filler
RCALC_CMG_TXT RCALC_CMG_TXT Calc Text 10 2138-2147 Recalculated CMG Code
RCALC_CMG_VRSN_TXT RCALC_CMG_VRSN_TXT Calc Text 10 2158-2167 Recalculated CMG Version Code
ASSESSMENT_ID ASSESSMENT_ID Calc Number 15 2168-2182 Assessment ID
ORIGINAL_ASSESSMENT_ID ORIGINAL_ASSESSMENT_ID Calc Number 15 2183-2197 Original Assessment ID
RESIDENT_INTERNAL_ID RESIDENT_INTERNAL_ID Calc Number 10 2198-2207 Resident ID
PROVIDER_INTERNAL_ID PROVIDER_INTERNAL_ID Calc Number 10 2208-2217 Provider Internal Number
SUBMISSION_ID SUBMISSION_ID Calc Number 15 2218-2232 Submission ID
SUBMISSION_DATE SUBMISSION_DATE Calc Date 8 2233-2240 Submission Date
SUBMISSION_COMPLETE_DATE SUBMISSION_COMPLETE_DATE Calc Date 8 2241-2248 Submission Complete Date
SUBMITTING_USER_ID SUBMITTING_USER_ID Calc Text 30 2249-2278 Submitting User ID
BIRTHDATE_SUBMIT_CODE BIRTHDATE_SUBMIT_CODE Calc Code 1 2279-2279 Birthdate Submit Code
RESIDENT_MATCH_CRITERIA RESIDENT_MATCH_CRITERIA Calc Number 2 2280-2281 Resident Matching Criteria
RESIDENT_AGE RESIDENT_AGE Calc Number 3 2282-2284 Resident Age
C_MOTOR_SCRE_TXT C_MOTOR_SCRE_TXT Calc Text 5 2285-2289 Calculated Motor Score
C_CGNTV_SCRE_TXT C_CGNTV_SCRE_TXT Calc Text 5 2290-2294 Calculated Cognitive Score
C_CMG_DLL_VRSN_CD C_CMG_DLL_VRSN_CD Calc Text 10 2295-2304 Calculated CMG dll version
C_CCN_NUM C_CCN_NUM Calc Text 12 2305-2316 CMS Certification Number
CALC_FILLER CALC_FILLER Calc Text 468 2317-2784 Calculated items filler
DATA_END_INDICATOR DATA_END_INDICATOR Calc Text 1 2785-2785 End of Data Terminator Code
CR CR Calc Text 1 2786-2786 Carriage Return
LF LF Calc Text 1 2787-2787 Line Feed

NOTICE: These materials are in the public domain and cannot be copyrighted.
Generated: 08/31/2016 10:31:00 AM