IRF-PAI Tier Assignment Worksheet
Use this worksheet during medical record review to systematically document comorbidity evidence
Patient Information
Comorbidity Documentation Checklist
For each comorbidity, verify ALL three criteria are met and document evidence source
| ☐ | Comorbidity / ICD-10 | Physician Documented? (H&P, Progress Note) | Actively Treated? (Meds, Labs, Monitoring) | Clinical Impact? (Affects rehab/LOS) |
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⚠High-Impact Comorbidities (Often Tier 3)
Infections:
- Sepsis (A41.9)
- Pneumonia (J18.9)
- UTI (N39.0)
- Wound infection (L08.9)
Acute Conditions:
- Acute kidney injury (N17.9)
- Acute CHF exacerbation (I50.9)
- Acute respiratory failure (J96.00)
- DVT/PE (I26.99, I82.409)
Tier Assignment Logic
TIER 1
No comorbidities OR only low-impact comorbidities
Examples: Well-controlled HTN, hyperlipidemia, osteoarthritis
TIER 2
1-2 moderate comorbidities requiring active treatment
Examples: Diabetes with insulin, COPD on bronchodilators, CKD Stage 3
TIER 3
3+ comorbidities OR 1+ high-impact condition
Examples: Sepsis, pneumonia, acute CHF, multiple chronic conditions
Final Tier Assignment
Total Comorbidities Documented:
___
High-Impact Conditions:
___
Assigned Tier:
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✓Quality Control Checklist
All comorbidities have physician documentation with date and signature
Active treatment evidence documented for each comorbidity (medications, labs, monitoring)
Clinical impact on rehabilitation or LOS verified for each comorbidity
ICD-10 codes verified against medical record and coding guidelines
Tier assignment matches comorbidity count and high-impact condition logic
Physician query submitted if discrepancies or unclear documentation identified
Completed by:
Date:
Oasis Point Rehabilitation Hospital | IRF-PAI Accuracy Training Platform