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Centers for Medicare & Medicaid Services - August 2009
(M1610) Urinary Incontinence or Urinary Catheter Presence:
0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)
1 - Patient is incontinent
2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)
(M1620) Bowel Incontinence Frequency:
0 - Very rarely or never has bowel incontinence
1 - Less than once weekly
2 - One to three times weekly
3 - Four to six times weekly
4 - On a daily basis
5 - More often than once daily
NA - Patient has ostomy for bowel elimination
UK - Unknown [Omit “UK” option on FU, DC]
(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within
the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or
treatment regimen?
0 - Patient does not have an ostomy for bowel elimination.
1 - Patient's ostomy was not related to an inpatient stay and did not necessitate change in medical or
treatment regimen.
2 - The ostomy was related to an inpatient stay or did necessitate change in medical or treatment
regimen.
(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments,
pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper
body without assistance.
1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.
2 - Someone must help the patient put on upper body clothing.
3 - Patient depends entirely upon another person to dress the upper body.
(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments,
slacks, socks or nylons, shoes:
0 - Able to obtain, put on, and remove clothing and shoes without assistance.
1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the
patient.
2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.
3 - Patient depends entirely upon another person to dress lower body.
(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing
hands, and shampooing hair).
0 - Able to bathe self in shower or tub independently, including getting in and out of tub/shower.
1 - With the use of devices, is able to bathe self in shower or tub independently,
2 - Able to bathe in shower or tub with the intermittent assistance of another person:
(a) for intermittent supervision or encouragement or reminders, OR
(b) to get in and out of the shower or tub, OR
(c) for washing difficult to reach areas.
3 - Able to participate in bathing self in shower or tub, but requires presence of another person
throughout the bath for assistance or supervision.
4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of
devices at the sink, in chair, or on commode.
5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in
bedside chair, or on commode, with the assistance or supervision of another person throughout
the bath.
6 - Unable to participate effectively in bathing and is bathed totally by another person.
Clinician’s signature/Date __________________________________________________