Version 2.78

95032-9 Functional Abilities and Goals

Observation ID in Form

GG

Fully-Specified Name

Component
FASI v1.0 - Functional Abilities and Goals
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95020-4 Self-Care

Observation ID in Form

GG0130

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's self-care performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Self-care
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94849-7 Self-Care.Usual

Observation ID in Form

GG0130_7

Fully-Specified Name

Component
FASI v1.0 - Self-care - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95019-6 Eating

Term Description

The patient's usual ability to use suitable utensils to bring food/liquid to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.
Source: Regenstrief LOINC

Observation ID in Form

GG0130A7

Form Context

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 person

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Eating - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95018-8 Oral hygiene

Observation ID in Form

GG0130B7

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Oral hygiene - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95017-0 Toileting hygiene

Observation ID in Form

GG0130CC7

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toileting hygiene - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95016-2 Wash upper body

Observation ID in Form

GG0130D7

Form Context

The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wash upper body - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]

95015-4 Shower/bathe self

Observation ID in Form

GG0130EE7

Form Context

The ability to bathe self including washing, rinsing, and drying self . Does not include transferring in/out of tub/shower

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Shower &or bathe self - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95014-7 Upper body dressing

Observation ID in Form

GG0130F7

Form Context

The ability to dress and undress above the waist, including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Upper body dressing - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95013-9 Lower body dressing

Observation ID in Form

GG0130G7

Form Context

The ability to dress and undress below the waist, including fasteners; does not include footwear

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lower body dressing - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95012-1 Putting on/taking off footwear

Observation ID in Form

GG0130H7

Form Context

The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Putting on &or taking off footwear - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94850-5 Self-Care.Most Dependent

Observation ID in Form

GG0130_8

Fully-Specified Name

Component
FASI v1.0 - Self-care - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94933-9 Eating

Observation ID in Form

GG0130A8

Form Context

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 person

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Eating - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94934-7 Oral hygiene

Observation ID in Form

GG0130B8

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Oral hygiene - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95043-6 Toileting hygiene

Observation ID in Form

GG0130CC8

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toileting hygiene - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94935-4 Wash upper body

Observation ID in Form

GG0130D8

Form Context

The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wash upper body - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94936-2 Shower/bathe self

Observation ID in Form

GG0130EE8

Form Context

The ability to bathe self including washing, rinsing, and drying self . Does not include transferring in/out of tub/shower

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Shower &or bathe self - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94937-0 Upper body dressing

Observation ID in Form

GG0130F8

Form Context

The ability to dress and undress above the waist, including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Upper body dressing - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94938-8 Lower body dressing

Observation ID in Form

GG0130G8

Form Context

The ability to dress and undress below the waist, including fasteners; does not include footwear

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lower body dressing - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94939-6 Putting on/taking off footwear

Observation ID in Form

GG0130H8

Form Context

The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Putting on and taking off footwear - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94876-0 Self-Care Priorities

Observation ID in Form

GG0135

Form Context

Please ask the person to describe at least one or two personal priorities in the area of self-care for the next six months. If the person does not express any personal priorities in this area, please note this below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Self-care priorities for the next 6Mo
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nar
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95023-8 Mobility

Observation ID in Form

GG0170

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's transfer/bed mobility performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Mobility
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94851-3 Mobility.Usual

Observation ID in Form

GG0170_7

Fully-Specified Name

Component
FASI v1.0 - Mobility - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95011-3 Roll left and right

Observation ID in Form

GG0170A7

Form Context

The ability to roll from lying on back to left and right side, and return to lying on back

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Roll left and right - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95010-5 Sit to lying

Observation ID in Form

GG0170B7

Form Context

The ability to move from sitting on side of bed to lying flat on the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to lying - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95009-7 Lying to sitting on side of bed

Observation ID in Form

GG0170C7

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lying to sitting on side of bed - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95008-9 Sit to stand

Observation ID in Form

GG0170D7

Form Context

The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to stand - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95007-1 Chair/bed-to-chair transfer

Observation ID in Form

GG0170E7

Form Context

The ability to transfer to and from a bed to a chair (or wheelchair)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Chair &or bed-to-chair transfer - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95006-3 Toilet transfer

Observation ID in Form

GG0170F7

Form Context

The ability to get on and off a toilet or commode

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toilet transfer - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95005-5 Car transfer

Observation ID in Form

GG0170G7

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Car transfer - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94932-1 Does the patient walk?

Observation ID in Form

GG0170HH7

Skip Logic

If 0, Skip to GG0175A. If 1, Skip to GG0175A. If 2, Continue to GG0170I.

Fully-Specified Name

Component
Does the patient walk
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.78: ANSWER_LIST_TYPE: FASI V1.1; Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL4183-1

Answer Code Score Answer ID
No, and walking goal is not clinically indicated 0 LA26845-0
No, and walking goal is clinically indicated 1 LA26846-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 2 LA33-6

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95004-8 Walks 10 feet

Observation ID in Form

GG0170I7

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0170M

Form Context

Once standing, the ability to walk at least 10 feet in a room, corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 10 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Corrected "Walks" to "Walk" to for consistency across CMS assessment forms.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95003-0 Walks 50 feet with two turns

Observation ID in Form

GG0170J7

Form Context

Once standing, the ability to walk at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 50 feet with two turns - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Corrected "Walks" to "Walk" to for consistency across CMS assessment forms.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95002-2 Walks 150 feet

Observation ID in Form

GG0170K7

Form Context

Once standing, the ability to walk at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 150 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Corrected "Walks" to "Walk" to for consistency across CMS assessment forms.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95001-4 Walks 10 feet on uneven surfaces

Observation ID in Form

GG0170L7

Form Context

The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walking 10 feet on uneven surfaces - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

95000-6 1 step (curb)

Observation ID in Form

GG0170M7

Form Context

The ability to go up and down a curb or up and down one step

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down a curb &or step - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94999-0 4 steps

Observation ID in Form

GG0170N7

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0170P.

Form Context

The ability to go up and down four steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 4 steps - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94998-2 12 steps

Observation ID in Form

GG0170O7

Form Context

The ability to go up and down 12 steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 12 steps - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94997-4 Picking up object

Observation ID in Form

GG0170P7

Form Context

The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Picking up object - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94996-6 Walk indoors

Observation ID in Form

GG0170U7

Form Context

The ability to walk from room to room, around furniture and other obstacles

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks indoors - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94995-8 Carries something in both hands

Observation ID in Form

GG0170V7

Form Context

The ability to carry something in both hands while walking indoors e.g. several dishes, light laundry basket, tray with food

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Carries something in both hands - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94994-1 Walks for 15 minutes

Observation ID in Form

GG0170W7

Form Context

The ability to walk for 15 minutes without stopping or resting (e.g., department store, supermarket.)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks for 15M - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94993-3 Walks across a street

Observation ID in Form

GG0170X7

Form Context

The ability to cross street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks across a street - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94852-1 Mobility.Most Dependent

Observation ID in Form

GG0170_8

Fully-Specified Name

Component
FASI v1.0 - Mobility - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94940-4 Roll left and right

Observation ID in Form

GG0170A8

Form Context

The ability to roll from lying on back to left and right side, and return to lying on back

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Roll left and right - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94941-2 Sit to lying

Observation ID in Form

GG0170B8

Form Context

The ability to move from sitting on side of bed to lying flat on the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to lying - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94942-0 Lying to sitting on side of bed

Observation ID in Form

GG0170C8

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Lying to sitting on side of bed - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94943-8 Sit to stand

Observation ID in Form

GG0170D8

Form Context

The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Sit to stand - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94944-6 Chair/bed-to-chair transfer

Observation ID in Form

GG0170E8

Form Context

The ability to transfer to and from a bed to a chair (or wheelchair)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Chair &or bed-to-chair transfer - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Change Reason
Release 2.69: COMPONENT: Updated for consistency across terms and to clarify that assessment is for transfer from a chair and/or bed to a chair.;
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94945-3 Toilet transfer

Observation ID in Form

GG0170F8

Form Context

The ability to get on and off a toilet or commode

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Toilet transfer - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94946-1 Car transfer

Observation ID in Form

GG0170G8

Form Context

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

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Car transfer - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94947-9 Walks 10 feet

Observation ID in Form

GG0170I8

Form Context

Once standing, the ability to walk at least 10 feet in a room, corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 10 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94948-7 Walks 50 feet with two turns

Observation ID in Form

GG0170J8

Form Context

Once standing, the ability to walk at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 50 feet with two turns - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94949-5 Walks 150 feet

Observation ID in Form

GG0170K8

Form Context

Once standing, the ability to walk at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walk 150 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94950-3 Walks 10 feet on uneven surfaces

Observation ID in Form

GG0170L8

Form Context

The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walking 10 feet on uneven surfaces - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94951-1 1 step (curb)

Observation ID in Form

GG0170M8

Form Context

The ability to go up and down a curb or up and down one step

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down a curb &or step - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94952-9 4 steps

Observation ID in Form

GG0170N8

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0170P.

Form Context

The ability to go up and down four steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 4 steps - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94953-7 12 steps

Observation ID in Form

GG0170O8

Form Context

The ability to go up and down 12 steps with or without a rail

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Go up and down 12 steps - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94954-5 Picking up object

Observation ID in Form

GG0170P8

Form Context

The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Picking up object - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94955-2 Walks indoors

Observation ID in Form

GG0170U8

Form Context

The ability to walk from room to room, around furniture and other obstacles

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks indoors - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94956-0 Carries something in both hands

Observation ID in Form

GG0170V8

Form Context

The ability to carry something in both hands while walking indoors e.g. several dishes, light laundry basket, tray with food

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Carries something in both hands - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94957-8 Walks for 15 minutes

Observation ID in Form

GG0170W8

Form Context

The ability to walk for 15 minutes without stopping or resting (e.g., department store, supermarket.)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks for 15M - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94958-6 Walks across a street

Observation ID in Form

GG0170X8

Form Context

The ability to cross street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Walks across a street - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95131-9 Mobility (Wheelchair)

Observation ID in Form

GG0175

Fully-Specified Name

Component
FASI v1.0 - Mobility (Wheelchair)
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95021-2 Does the person use a manual wheelchair?

Observation ID in Form

GG0175A

Skip Logic

If 0, Skip to GG0175F. If 1, Continue to GG0175B.

Fully-Specified Name

Component
Manual wheelchair use
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL251-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95024-6 Manual wheelchair.Usual

Observation ID in Form

GG0175_7

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's wheelchair mobility performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Manual wheelchair - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94992-5 Wheel 50 feet with two turns

Observation ID in Form

GG0175B7

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0175E

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94991-7 Wheels 150 feet

Observation ID in Form

GG0175C7

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94990-9 Wheels for 15 minutes

Observation ID in Form

GG0175D7

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15 minutes - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94989-1 Wheels across a street

Observation ID in Form

GG0175E7

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95025-3 Manual Wheelchair.Most Dependent

Observation ID in Form

GG0175_8

Fully-Specified Name

Component
FASI v1.0 - Manual wheelchair - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94959-4 Wheel 50 feet with two turns

Observation ID in Form

GG0175B8

Skip Logic

If usual and most dependent performance are coded 07, 11, or 90, skip to GG0175E

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94960-2 Wheels 150 feet

Observation ID in Form

GG0175C8

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94961-0 Wheels for 15M

Observation ID in Form

GG0175D8

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15M - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94962-8 Wheels across a street

Observation ID in Form

GG0175E8

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95022-0 Does the person use a motorized wheelchair and/or scooter?

Observation ID in Form

GG0175F

Skip Logic

If 0, Skip to GG0185. If 1, Continue to GG0175G.

Fully-Specified Name

Component
Motorized wheelchair &or scooter use
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL251-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95027-9 Motorized Wheelchair/Scooter.Usual

Observation ID in Form

GG0175_7

Form Coding Instructions

Code the person's usual performance during the past 3 days using the 6-point scale in Column A. If the person's performance changed during the past month, also code their most dependent performance in Column B. If the person's wheelchair mobility performance was unchanged during the past month, column B should be coded the same as column A. If the activity was not attempted, code the reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Motorized wheelchair &or scooter - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94992-5 Wheel 50 feet with two turns

Observation ID in Form

GG0175G7

Skip Logic

If usual and most dependent performance are coded 07, 11,or 90, skip to GG0175J.

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99153-9 Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94991-7 Wheels 150 feet

Observation ID in Form

GG0175H7

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

94990-9 Wheels for 15 minutes

Observation ID in Form

GG0175I7

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15 minutes - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94989-1 Wheels across a street

Observation ID in Form

GG0175J7

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95026-1 Motorized Wheelchair/Scooter.Most Dependent

Observation ID in Form

GG0175_8

Fully-Specified Name

Component
FASI v1.0 - Motorized wheelchair &or scooter - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94959-4 Wheel 50 feet with two turns

Observation ID in Form

GG0175G8

Skip Logic

If usual and most dependent performance are coded 07, 11,or 90, skip to GG0175J.

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 50 feet with two turns - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94960-2 Wheels 150 feet

Observation ID in Form

GG0175H8

Form Context

Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheel 150 feet - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94961-0 Wheels for 15M

Observation ID in Form

GG0175I8

Form Context

Once seated in wheelchair/scooter, the ability to wheel without stopping or resting (e.g., through a department store, supermarket)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels for 15M - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94962-8 Wheels across a street

Observation ID in Form

GG0175J8

Form Context

Once seated in wheelchair/scooter, the ability to wheel across a street before light turns red

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Wheels across a street - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94877-8 Mobility Priorities

Observation ID in Form

GG0180

Form Coding Instructions

Please ask the person to describe at least one or two personal priorities in the area of mobility for the next six months. If the person does not express any personal priorities in this area, please note this below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Mobility priorities for the next 6Mo
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nar
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95028-7 Instrumental Activities of Daily Living (IADL)

Observation ID in Form

GG0185

Form Coding Instructions

Code the person's Usual performance during the past 3 days using the 6-point scale. If the person's performance changed during the past month, also code their Most Dependent performance. If the person's IADL performance was unchanged during the past month, the Most Dependent should be coded the same as the level recorded in Usual. If the activity was not attempted, document using a Not Attempted code reason. Safety and Quality of Performance - If helper assistance is required because person's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Instrumental Activities of Daily Living
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95029-5 Instrumental Activities of Daily Living.Usual

Observation ID in Form

GG0185_7

Fully-Specified Name

Component
FASI v1.0 - Instrumental Activities of Daily Living - usual performance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94976-8 Makes a light cold meal

Observation ID in Form

GG0185A7

Form Context

The ability to plan and prepare all aspects of a light cold meal such as a bowl of cereal and sandwich and cold drink

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Makes a light cold meal - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94977-6 Makes a light hot meal

Observation ID in Form

GG0185B7

Form Context

The ability to plan and prepare all aspects of a light hot meal such as heating a bowl of soup and reheating a prepared meal

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Makes a light hot meal - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94978-4 Light daily housework

Observation ID in Form

GG0185C7

Form Context

The ability to complete light daily housework to maintain a safe home environment such that the person is not at risk for harm within their home. Examples include wiping counter tops or doing dishes

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Light daily housework - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94979-2 Heavier periodic housework

Observation ID in Form

GG0185D7

Form Context

The ability to complete heavier periodic housework to maintain a safe home environment such that person is not at risk for harm within their home. Examples include doing laundry, vacuuming, cleaning bathroom

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Heavier periodic housework - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94980-0 Light shopping

Observation ID in Form

GG0185E7

Form Coding Instructions

Once at store, can locate and select up to five needed goods, take to check out, and complete purchasing transaction

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Light shopping - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94981-8 Telephone-answering call

Observation ID in Form

GG0185F7

Form Context

The ability to answer call in person's customary manner and maintain for 1 minute or longer. Does not include getting to the phone

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Answering telephone call - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94982-6 Telephone-placing call

Observation ID in Form

GG0185G7

Form Context

The ability to place call in person's customary manner and maintain for 1 minute or longer. Does not include getting to the phone

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Placing telephone call - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94983-4 Medication management-oral medications

Observation ID in Form

GG0185H7

Form Context

The ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medication management.oral medications - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94984-2 Medication management-inhalant/mist medications

Observation ID in Form

GG0185I7

Form Context

The ability to prepare and take all prescribed inhalant/mist medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medication management.inhalant &or mist medications - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94985-9 Medication management-injectable medications

Observation ID in Form

GG0185J7

Form Context

The ability to prepare and take all prescribed injectable medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medication management.injectable medications - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94986-7 Simple financial management

Observation ID in Form

GG0185K7

Form Context

The ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Simple financial management - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94987-5 Complex financial management

Observation ID in Form

GG0185L7

Form Context

The ability to complete financial decision-making such as budget and remembering to pay bills

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Complex financial management - usual functional ability
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95030-3 Instrumental Activities of Daily Living.Most Dependent

Observation ID in Form

GG0185_8

Fully-Specified Name

Component
FASI v1.0 - Instrumental Activities of Daily Living - most dependent performance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94963-6 Makes a light cold meal

Observation ID in Form

GG0185A8

Form Context

The ability to plan and prepare all aspects of a light cold meal such as a bowl of cereal and sandwich and cold drink

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Makes a light cold meal - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94964-4 Makes a light hot meal

Observation ID in Form

GG0185B8

Form Context

The ability to plan and prepare all aspects of a light hot meal such as heating a bowl of soup and reheating a prepared meal

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Makes a light hot meal - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94965-1 Light daily housework

Observation ID in Form

GG0185C8

Form Context

The ability to complete light daily housework to maintain a safe home environment such that the person is not at risk for harm within their home. Examples include wiping counter tops or doing dishes

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Light daily housework - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94966-9 Heavier periodic housework

Observation ID in Form

GG0185D8

Form Context

The ability to complete heavier periodic housework to maintain a safe home environment such that person is not at risk for harm within their home. Examples include doing laundry, vacuuming, cleaning bathroom

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Heavier periodic housework - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94967-7 Light shopping

Observation ID in Form

GG0185E8

Form Coding Instructions

Once at store, can locate and select up to five needed goods, take to check out, and complete purchasing transaction

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Light shopping- most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94968-5 Telephone-answering call

Observation ID in Form

GG0185F8

Form Context

The ability to answer call in person's customary manner and maintain for 1 minute or longer. Does not include getting to the phone

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Answering telephone call - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94969-3 Telephone-placing call

Observation ID in Form

GG0185G8

Form Context

The ability to place call in person's customary manner and maintain for 1 minute or longer. Does not include getting to the phone

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Placing telephone call - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94970-1 Medication management-oral medications

Observation ID in Form

GG0185H8

Form Context

The ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medication management.oral medications - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94971-9 Medication management-inhalant/mist medications

Observation ID in Form

GG0185I8

Form Context

The ability to prepare and take all prescribed inhalant/mist medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medication management.inhalant &or mist medications - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94972-7 Medication management-injectable medications

Observation ID in Form

GG0185J8

Form Context

The ability to prepare and take all prescribed injectable medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medication management.injectable medications - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94973-5 Simple financial management

Observation ID in Form

GG0185K8

Form Context

The ability to complete financial transactions such as counting coins, verifying change for a single item transaction, writing a check, online/mobile bill pay, banking, or shopping

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Simple financial management - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94974-3 Complex financial management

Observation ID in Form

GG0185L8

Form Context

The ability to complete financial decision-making such as budget and remembering to pay bills

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Complex financial management - most dependent performance during the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5571-6

Answer Code Score Answer ID
Independent - Person completes the activity by themself with no assistance from a helper. 06 LA30909-8
Setup or cleanup assistance - Helper sets up or cleans up; person completes activity. Helper assists only prior to or following the activity. 05 LA30910-6
Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as person completes activity. Assistance may be provided throughout the activity or intermittently. 04 LA30911-4
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. 03 LA10055-4
Substantial/maximal assistance - Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 02 LA11759-0
Dependent - Helper does all of the effort. Person does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the person to complete the activity. 01 LA30914-8
Person refused. 07 LA30915-5
Not applicable - Person does not usually do this activity. 11 LA30916-3
Not attempted due to short-term medical condition or safety concerns. 90 LA30917-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94878-6 IADL Priorities

Observation ID in Form

GG0190

Form Coding Instructions

Please ask the person to describe at least one or two personal priorities in the area of instrumental activities of daily living for the next six months. If the person does not express any personal priorities in this area, please note this below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Instrumental activities of daily living priorities for the next 6Mo
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nar
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95031-1 Assistive Devices for Everyday Activities

Observation ID in Form

GG0125

Form Coding Instructions

Identify the person's need for and availability of each assistive device. If no assistive device is needed to complete self-care, mobility, and/or instrumental activities of daily living, code as Not applicable (11). If device is not used, document using a Not Used code reason. Code the person's usual need for, and availability of, assistive devices to complete self-care, mobility, and/or instrumental activities of daily living

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Assistive Devices for Everyday Activities
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95042-8 In the past month, has the person used, or expressed or demonstrated a need for an assistive device?

Observation ID in Form

GG0125AA

Fully-Specified Name

Component
Used or needed assistive devices in the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL251-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94879-4 Cane/crutch

Observation ID in Form

GG0125A

Fully-Specified Name

Component
Need for and availability of a cane &or crutch
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94880-2 Walker

Observation ID in Form

GG0125B

Fully-Specified Name

Component
Need for and availability of a walker
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94881-0 Standard folding walker

Observation ID in Form

GG0125B1

Fully-Specified Name

Component
Need for and availability of a standard folding walker
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94882-8 Walker with seat

Observation ID in Form

GG0125B2

Fully-Specified Name

Component
Need for and availability of a walker with seat
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94883-6 Walker wtih wheels

Observation ID in Form

GG0125B3

Fully-Specified Name

Component
Need for and availability of a walker with wheels
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94884-4 Wheelchair

Observation ID in Form

GG0125C

Fully-Specified Name

Component
Need for and availability of a wheelchair
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94885-1 Manual wheelchair

Observation ID in Form

GG0125C1

Fully-Specified Name

Component
Need for and availability of a manual wheelchair
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94886-9 Motorized wheelchair and/or scooter

Observation ID in Form

GG0125C2

Fully-Specified Name

Component
Need for and availability of a motorized wheelchair &or scooter
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94887-7 Limb prosthesis

Observation ID in Form

GG0125D

Fully-Specified Name

Component
Need for and availability of a limb prosthesis
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94888-5 Specialized seating pad (e.g. air-filled, gel, shaped foam)

Observation ID in Form

GG0125E

Fully-Specified Name

Component
Need for and availability of a specialized seating pad
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94889-3 Mechanical lift

Observation ID in Form

GG0125F

Fully-Specified Name

Component
Need for and availability of a mechanical lift
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94890-1 Reacher/Grabber

Observation ID in Form

GG0125G

Fully-Specified Name

Component
Need for and availability of a reacher &or grabber
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94891-9 Sock aid

Observation ID in Form

GG0125H

Fully-Specified Name

Component
Need for and availability of a sock aid
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94892-7 Orthotics/Brace

Observation ID in Form

GG0125I

Fully-Specified Name

Component
Need for and availability of an orthotic &or brace
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94893-5 Bed rail

Observation ID in Form

GG0125J

Fully-Specified Name

Component
Need for and availability of a bed rail
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94894-3 Electronic bed

Observation ID in Form

GG0125K

Fully-Specified Name

Component
Need for and availability of an electronic bed
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94895-0 Grab bars

Observation ID in Form

GG0125L

Fully-Specified Name

Component
Need for and availability of grab bars
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94896-8 Transfer board

Observation ID in Form

GG0125M

Fully-Specified Name

Component
Need for and availability of a transfer board
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94897-6 Shower/commode chair

Observation ID in Form

GG0125N

Fully-Specified Name

Component
Need for and availability of a shower &or commode chair
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94898-4 Walk/wheel-in shower

Observation ID in Form

GG0125O

Fully-Specified Name

Component
Need for and availability of a walk or wheel-in shower
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94899-2 Glasses or contact lenses

Observation ID in Form

GG0125P

Fully-Specified Name

Component
Need for and availability of glasses or contact lenses
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94900-8 Hearing aid

Observation ID in Form

GG0125Q

Fully-Specified Name

Component
Need for and availability of a hearing aid
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94901-6 Communication device

Observation ID in Form

GG0125R

Fully-Specified Name

Component
Need for and availability of a communication device
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94902-4 Stair rails

Observation ID in Form

GG0125S

Fully-Specified Name

Component
Need for and availability of stair rails
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94903-2 Lift chair

Observation ID in Form

GG0125T

Fully-Specified Name

Component
Need for and availability of a lift chair
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94904-0 Ramps

Observation ID in Form

GG0125U

Fully-Specified Name

Component
Need for and availability of ramps
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94905-7 Raised toilet seat

Observation ID in Form

GG0125V

Fully-Specified Name

Component
Need for and availability of a raised toilet seat
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94906-5 Glucometer

Observation ID in Form

GG0125W

Fully-Specified Name

Component
Need for and availability of a glucometer
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94907-3 CPAP

Observation ID in Form

GG0125X

Fully-Specified Name

Component
Need for and availability of Continuous Positive Airway Pressure device
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94908-1 Oxygen concentrator

Observation ID in Form

GG0125Y

Fully-Specified Name

Component
Need for and availability of an oxygen concentrator
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94910-7 Other

Observation ID in Form

GG0125Z

Fully-Specified Name

Component
Need for and availability of other assistive devices
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Example Answer List LL5572-4

Answer Code Score Answer ID
Assistive device needed and available - Person needs this device to complete daily activities and has the device in the home. 02 LA30918-9
Assistive device needed but current device unsuitable - Device is in home but no longer meets person's needs. 01 LA30919-7
Assistive device needed but not available - Person needs the device but it is not available in the home. 00 LA30920-5
Person refused - Person chooses to not use needed device. 07 LA30921-3
Not applicable - Person does not need this device. 11 LA30922-1

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94909-9 Specify:

Observation ID in Form

GG0125Z_Specify

Fully-Specified Name

Component
Assistive devices needed
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nom
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL5581-5

Answer Code Score Answer ID
Stair glide LA30948-6
Pillbox LA30949-4
Cognitive aids, such as computer or electrical assistive devices to aid in memory, attention or other cognitive challenges LA30950-2
Voice recognition program LA30951-0
Computer or device screen reader LA30952-8
Computer screen enlargement applications LA30953-6
Automatic page turners LA30954-4
Book holder LA30955-1
Adapted pencil grips LA30956-9
Adaptive switches LA30957-7

Member of these Panels

LOINC Long Common Name
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95033-7 Preferences for Customary Routine and Activities

Observation ID in Form

F

Fully-Specified Name

Component
FASI v1.0 - Preferences for Customary Routine and Activities
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95413-1 Living Arrangements. Identify the person's usual living arrangement during the Past 3 Days and the Past Month.

Observation ID in Form

F0900A

Fully-Specified Name

Component
Living arrangement panel
Property
-
Time
-
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94988-3 Living Arrangements, Identify the person's usual living arrangement during the past 3 days.

Observation ID in Form

F0900A1

Fully-Specified Name

Component
Living arrangement
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nom
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5574-0

Answer Code Score Answer ID
Person lives alone - no other residents in the home. 05 LA30925-4
Person lives with others in the home - for example, family, friends, or paid caregiver. 04 LA30926-2
Person lives in congregate home - for example, assisted living, or residential care home. 03 LA30927-0
Person does not have a permanent home or is homeless. 02 LA30928-8
Person was in a medical facility. 01 LA30929-6

Member of these Panels

LOINC Long Common Name
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94975-0 Living Arrangements, Identify the person's usual living arrangement during the past month.

Observation ID in Form

F0900A2

Fully-Specified Name

Component
Living arrangement during the past 1Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Nom
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5574-0

Answer Code Score Answer ID
Person lives alone - no other residents in the home. 05 LA30925-4
Person lives with others in the home - for example, family, friends, or paid caregiver. 04 LA30926-2
Person lives in congregate home - for example, assisted living, or residential care home. 03 LA30927-0
Person does not have a permanent home or is homeless. 02 LA30928-8
Person was in a medical facility. 01 LA30929-6

Member of these Panels

LOINC Long Common Name
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94911-5 Living Arrangement Priorities

Observation ID in Form

F0905

Form Coding Instructions

Please ask the person to describe at least one or two personal priorities in the area of living arrangements for the next six months. If the person does not express any personal priorities in this area, please note this below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Living arrangement priorities for the next 6Mo
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nar
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Change Reason
Release 2.78: ORDER_OBS: FASI v1.1; Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95034-5 Availability of Assistance

Observation ID in Form

F0910

Fully-Specified Name

Component
FASI v1.0 - Availability of Assistance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94912-3 Does the person have assistance in their home?

Observation ID in Form

F0910A

Skip Logic

If 0, Do not code availability of assistance - skip to question F0920. If 1, Continue to question F0910B.

Fully-Specified Name

Component
Availability of caregiver assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Normative Answer List LL251-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95414-9 Code the level of assistance in the person's home (both Paid and Unpaid) during the past month.

Observation ID in Form

F0910B

Fully-Specified Name

Component
Level of paid and unpaid caregiver assistance
Property
-
Time
1Mo
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94913-1 Code the level of assistance in the person's home during the past month - paid assistance

Observation ID in Form

F0910B1

Fully-Specified Name

Component
Level of paid caregiver assistance in the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5577-3

Answer Code Score Answer ID
No assistance received 05 LA12345-7
Occasional/short term assistance 04 LA30934-6
Regular night-time 03 LA30935-3
Regular daytime 02 LA12164-2
Around the clock 01 LA12163-4

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94914-9 Code the level of assistance in the person's home during the past month - unpaid assistance

Observation ID in Form

F0910B2

Fully-Specified Name

Component
Level of unpaid caregiver assistance in the past Mo
Property
Find
Time
1Mo
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.68
Order vs. Observation
Observation

Normative Answer List LL5577-3

Answer Code Score Answer ID
No assistance received 05 LA12345-7
Occasional/short term assistance 04 LA30934-6
Regular night-time 03 LA30935-3
Regular daytime 02 LA12164-2
Around the clock 01 LA12163-4

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95035-2 Availability of Paid and Unpaid Assistance

Observation ID in Form

F0920

Form Coding Instructions

Code the Paid and Unpaid caregiver's usual ability and willingness to provide assistance with each activity during the past 3 days. If the activity was not attempted, code as Not applicable (11). Code safety and quality of BOTH Paid and Unpaid caregiver assistance and their willingness to provide assistance with each of the following activities

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
FASI v1.0 - Availability of Paid and Unpaid Assistance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95036-0 Availability of Paid Assistance

Observation ID in Form

F0920_1

Fully-Specified Name

Component
FASI v1.0 - Availability of Paid Assistance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94915-6 Self-care assistance (for example, bathing, dressing, toileting, or eating/feeding).

Observation ID in Form

F0920A1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide self-care assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94917-2 Mobility assistance (for example, bed mobility, transfers, ambulating, or wheeling).

Observation ID in Form

F0920B1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide mobility assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94919-8 IADL assistance (for example, making meals, housekeeping, telephone, shopping, or finances).

Observation ID in Form

F0920C1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide instrumental activities of daily living assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94921-4 Medication administration (for example, oral, inhaled, or injectable medications).

Observation ID in Form

F0920D1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide medication administration assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94923-0 Medical procedures/treatments (for example, changing wound dressing, or home exercise program).

Observation ID in Form

F0920E1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide medical procedure &or treatment assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94925-5 Management of equipment (for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies).

Observation ID in Form

F0920F1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide management of equipment assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94927-1 Supervision (for example, due to safety concerns).

Observation ID in Form

F0920G1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide supervision
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94929-7 Advocacy or facilitation of person's participation in appropriate medical care (for example, transportation to or from appointments).

Observation ID in Form

F0920H1

Fully-Specified Name

Component
Paid caregiver's ability and willingness to provide advocacy or facilitation of person's participation
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

95037-8 Availability of Unpaid Assistance

Observation ID in Form

F0920_2

Fully-Specified Name

Component
FASI v1.0 - Availability of Unpaid Assistance
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.78
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94916-4 Self-care assistance (for example, bathing, dressing, toileting, or eating/feeding).

Observation ID in Form

F0920A2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide self-care assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94918-0 Mobility assistance (for example, bed mobility, transfers, ambulating, or wheeling).

Observation ID in Form

F0920B2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide mobility assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94920-6 IADL assistance (for example, making meals, housekeeping, telephone, shopping, or finances).

Observation ID in Form

F0920C2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide instrumental activities of daily living assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94922-2 Medication administration (for example, oral, inhaled, or injectable medications).

Observation ID in Form

F0920D2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide medication administration assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94924-8 Medical procedures/treatments (for example, changing wound dressing, or home exercise program).

Observation ID in Form

F0920E2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide medical procedure &or treatment assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94926-3 Management of equipment (for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies).

Observation ID in Form

F0920F2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide management of equipment assistance
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94928-9 Supervision (for example, due to safety concerns).

Observation ID in Form

F0920G2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide supervision
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94930-5 Advocacy or facilitation of person's participation in appropriate medical care (for example, transportation to or from appointments).

Observation ID in Form

F0920H2

Fully-Specified Name

Component
Unpaid caregiver's ability and willingness to provide advocacy or facilitation of person's participation
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.69
Order vs. Observation
Observation

Normative Answer List LL5578-1

Answer Code Score Answer ID
Assistance not needed - No assistance needed. 05 LA30938-7
Caregiver(s) currently provide assistance - Person's usual caregiver(s) willing and able to provide needed assistance. 04 LA30939-5
Caregiver(s) need training/supportive services to provide assistance - Caregiver(s) available and need assistance to provide support. 03 LA30940-3
Unclear if caregiver(s) will provide assistance - Caregiver(s) available in the home but it is not clear if caregiver(s) will provide needed assistance. 02 LA30941-1
Assistance needed but no caregiver(s) available - Person needs assistance but no caregiver(s) available in the home. 01 LA30942-9
Assistance needed but person declines assistance - Person needs caregiving but declines this assistance. 00 LA30943-7
Not applicable - Person does not do this activity. 11 LA30944-5

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]

94931-3 Caregiving Priorities

Observation ID in Form

F0925

Form Coding Instructions

Please ask the person to describe at least one or two personal priorities in the area of caregiving for the next six months. If the person does not express any personal priorities in this area, please note this below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Caregiving priorities for the next 6Mo
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nar
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.68
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
105175-4 Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment]
94848-9 Functional assessment standardized items (FASI) - version 1.0 [CMS Assessment]