Version 2.78

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]