| All benchmarks are from last
90 days |
| RIC
/ CMG |
| Impairment Group |
05.2 :
Unilateral upper extremity below the elbow (BE) |
| Rehab. Impairment
Category |
11 : Amputation,
other
|
| Case Mix Group |
1101 :
Amputation, non-lower extremity with motor score from
52-84
(determined by: RIC of 11 and Motor Score (77) between
52 and 84.) |
| Comorbidity Tier |
3 |
| HIPPS
Code |
D1101 |
|
| |
| Assessment
Dates |
| Date of Birth |
Jul 29, 1966 |
| Admit Date |
Nov
3, 2001 |
| Discharge Date |
Dec
12, 2001 |
| Follow-Up Date |
June
1, 2002 |
|
| Length
Of Stay (days) |
| Tier |
Patient |
Facility |
Region |
Nation |
Final Rule |
| 0 |
|
12
(+/- 5.9) |
11
(+/- 5.9) |
11.1
(+/- 5.9) |
12 |
| 3 |
39 |
15
(+/- 5.9) |
14.7
(+/- 5.9) |
14
(+/- 5.9) |
13 |
| 2 |
|
10
(+/- 5.9) |
12
(+/- 5.9) |
27.7
(+/- 13.3) |
11 |
| 1 |
|
20.1
(+/- 5.9) |
21.3
(+/- 5.9) |
19.4
(+/- 5.9) |
18 |
|
|
| |
| Medicare
Pricer |
| Facility
Adjuster |
Tier |
Federal
Rate |
Fac.
Adjusted Payment |
Payment
Weights |
0.905
(FY2001) |
0 |
$7,849.78 |
$7,104.05 |
0.6631 |
| 3 |
$8,462.99 |
$7,659.01 |
0.7149 |
| 2 |
$9,095.14 |
$8,231.10 |
0.7683 |
| 1 |
$14,940.70 |
$13,521.33 |
1.2621 |
| High
Cost Outlier |
| Patient cost,
which if exceeded would make this a high cost outlier |
| $17,804.96 |
|
| |
| Comorbidities |
| ICD |
Description |
Tier |
Excluded from
this RIC? |
| 1 |
2 |
3 |
| 496. |
CHR
AIRWAY OBSTRUCT NEC |
|
|
|
|
| 431. |
INTRACEREBRAL
HEMORRHAGE |
|
|
X |
No |
|
| Discharge
Setting % |
| This
Assessment: 01 - Home |
| Setting |
Facility |
Nation |
| 01 - Home |
79.68% |
77.68% |
| 04 - Intermediate
Care |
6.93% |
0.89% |
| 05 - Skilled
Nursing Facility |
0.89% |
0.89% |
| 07
- Acute unit of another facility |
0.89% |
8.93% |
| 10 - Other |
1.79% |
1.79% |
| 13 - Subacute
Setting |
1.79% |
1.79% |
| Not Provided |
8.04% |
8.04% |
|
| |
| Current
Assessment FIM Scores |
| |
Patient |
Facility |
Nation |
| |
Admit |
Disch |
Goal |
Gain
A-D |
Follow-Up |
Admit |
Disch |
Gain
A-D |
Follow-Up |
Admit |
Disch |
Gain
A-D |
Follow-Up |
| Motor |
77 |
84 |
- |
+7 |
88.7 |
76.3 |
85.1 |
+8.8 |
88.7 |
57.33 |
68.67 |
+11.34 |
88.7 |
| Cognitive |
35 |
35 |
- |
+0 |
36 |
35.7 |
35.9 |
+.2 |
36 |
35.7 |
35.9 |
+.2 |
36 |
| Total |
112 |
119 |
- |
+7 |
124.7 |
111.8 |
121.1 |
+9.3 |
124.0 |
89.67 |
103.33 |
+13.66 |
124.7 |
| |
| Eating |
7 |
7 |
- |
+0 |
6.92 |
6.80 |
6.70 |
-.1 |
6.92 |
6.80 |
6.70 |
-.1 |
6.92 |
| Grooming |
7 |
7 |
- |
+0 |
6.57 |
5.17 |
5.70 |
+.53 |
6.57 |
5.17 |
5.70 |
+.53 |
6.57 |
| Bathing |
7 |
7 |
- |
+0 |
5.87 |
4.60 |
4.93 |
+.33 |
5.87 |
4.60 |
4.93 |
+.33 |
5.87 |
| Dressing
- Upper |
5 |
7 |
- |
+2 |
6.52 |
5.50 |
6.00 |
+.5 |
6.52 |
5.50 |
6.00 |
+.5 |
6.52 |
| Dressing
- Lower |
6 |
7 |
- |
+1 |
5.96 |
4.97 |
5.77 |
+.8 |
5.96 |
4.97 |
5.77 |
+.8 |
5.96 |
| Toileting |
7 |
7 |
- |
+0 |
6.18 |
5.03 |
5.67 |
+.64 |
6.18 |
5.03 |
5.67 |
+.64 |
6.18 |
| Bladder |
5 |
7 |
- |
+2 |
6.59 |
6.17 |
6.50 |
+.33 |
6.59 |
6.17 |
6.50 |
+.33 |
6.59 |
| Bowel |
5 |
7 |
- |
+2 |
6.31 |
6.17 |
6.20 |
+.03 |
6.31 |
6.17 |
6.20 |
+.03 |
6.31 |
| Bed,
Chair, Wheelchair |
7 |
7 |
- |
+0 |
5.87 |
4.87 |
5.63 |
+.76 |
5.87 |
4.87 |
5.63 |
+.76 |
5.87 |
| Toilet
Trans |
7 |
7 |
- |
+0 |
5.88 |
5.03 |
5.60 |
+.57 |
5.88 |
5.03 |
5.60 |
+.57 |
5.88 |
| Tub,
Shower |
5 |
7 |
- |
+2 |
5.34 |
4.50 |
5.07 |
+.57 |
5.34 |
4.50 |
5.07 |
+.57 |
5.34 |
| Walk
/ Wheelchair |
7 (W) |
7 (W) |
- |
+0 |
5.77 |
4.37 |
5.47 |
+1.1 |
5.77 |
4.37 |
5.47 |
+1.1 |
5.77 |
| Stairs |
7 |
7 |
- |
+0 |
4.35 |
3.23 |
4.17 |
+.94 |
4.35 |
3.23 |
4.17 |
+.94 |
4.35 |
| Comprehension |
7 (B) |
7 (B) |
- |
+0 |
6.73 |
6.93 |
6.97 |
+.04 |
6.73 |
6.93 |
6.97 |
+.04 |
6.73 |
| Expression |
7 (B) |
7 (B) |
- |
+0 |
6.95 |
7.00 |
7.00 |
+0 |
6.95 |
7.00 |
7.00 |
+0 |
6.95 |
| Social
Interaction |
7 |
7 |
- |
+0 |
6.88 |
7.00 |
7.00 |
+0 |
6.88 |
7.00 |
7.00 |
+0 |
6.88 |
| Problem
Solving |
7 |
7 |
- |
+0 |
6.79 |
6.97 |
6.97 |
+0 |
6.79 |
6.97 |
6.97 |
+0 |
6.79 |
| Memory |
7 |
7 |
- |
+0 |
6.79 |
7.00 |
7.00 |
+0 |
6.79 |
7.00 |
7.00 |
+0 |
6.79 |
| |
*
One or more FIM goals have not been specified. |
|
| |
| CMG
Tiers |
| Tier |
Facility |
Nation |
| 0 |
2.00% |
69.64% |
| 3 |
2.00% |
26.79% |
| 2 |
2.00% |
3.57% |
| 1 |
2.00% |
.01% |
|
| %
High Cost Outliers |
| Tier |
Facility |
Nation |
| 0 |
2.00% |
5.00% |
| 3 |
2.00% |
2.00% |
| 2 |
2.00% |
33.00% |
| 1 |
2.00% |
2.00% |
|
| %
Transfers |
| Tier |
Facility |
Nation |
| 0 |
2.00% |
2.00% |
| 3 |
2.00% |
2.00% |
| 2 |
2.00% |
0.00% |
| 1 |
2.00% |
2.00% |
|
| |
