95026-1
Motorized Wheelchair/Scooter.Most Dependent
Active
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 ServicesFully-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
Long Common Name
Wheel 50 feet with two turns - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Wheel 150 feet - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Wheel 150 feet - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.69 (NAM)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-Specified Name
- Component
- Wheels for 15M - most dependent performance during the past Mo
- Property
- Find
- Time
- 1Mo
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Wheels for 15 minutes - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [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 ServicesFully-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
Long Common Name
Wheels across a street - most dependent performance during the past month [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.68
- Last Updated
- Version 2.68 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL4681-4
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Independent - Patient completes the activity by themself with no assistance from a helper. | 06 | LA9983-3 | |
| Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. | 05 | LA10073-7 | |
| Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. | 04 | LA28225-3 | |
| 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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity. | 01 | LA27665-1 | |
| Patient refused | 07 | LA10058-8 | |
| Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury. | 09 | LA28226-1 | |
| Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) | 10 | LA28227-9 | |
| Not attempted due to medical condition or safety concerns | 88 | LA26735-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 105175-4 | Functional assessment standardized items (FASI) - v1.1 during assessment period [CMS Assessment] |
| 106517-6 | Functional assessment standardized items (FASI) - v1.2 during assessment period [CMS Assessment] |
| 94848-9 | Functional assessment standardized items (FASI) - version 1.0 during assessment period [CMS Assessment] |