85906-6 Home health patient tracking sheet

Fully-Specified Name

Component

Home health patient tracking sheet - resumption of care

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

46498-2 Resumption of Care Date

Term Description

Date care resumed (e.g. the date of the first visit following an inpatient stay by a patient currently receiving service from a home health agency).
Source: Regenstrief LOINC

Observation ID in Form

M0032

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Resumption of care date

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57040-8 CLINICAL RECORD ITEMS

Fully-Specified Name

Component

Clinical record items

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

46500-5 Discipline of Person Completing Assessment

Term Description

Identifies the discipline of the clinician completing the comprehensive assessment at the specified time points or the clinician reporting the transfer to an inpatient facility, death at home, or discharge (no further visits after start of care).
Source: Regenstrief LOINC

Observation ID in Form

M0080

Fully-Specified Name

Component

Discipline of person completing assessment

Property

Type

Time

RptPeriod

System

Provider

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL245-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Nominal
• Persons
• Report period
• Survey
• Typ

Related Codes

46501-3 Date Assessment Completed

Term Description

The actual date the assessment is completed, except if agency policy allows assessments to be performed over more than one visit date, in which case the last date (when the assessment is finished) is the appropriate date to record.
Source: Regenstrief LOINC

Observation ID in Form

M0090

Fully-Specified Name

Component

Date assessment information completed

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57200-8 This Assessment is Currently Being Completed for the Following Reason:

Observation ID in Form

M0100

Fully-Specified Name

Component

Reason for assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL773-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

57201-6 Date of Physician-ordered Start of Care (Resumption of Care)

Observation ID in Form

M0102

Skip Logic

If date entered, go to M0110.

Fully-Specified Name

Component

Date of Physician-ordered Start of Care (Resumption of Care)

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Started
• Survey

Example Units

Related Codes

57202-4 Date of Referral

Observation ID in Form

M0104

Form Coding Instructions

Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA

Fully-Specified Name

Component

Date of Referral

Property

Date

Time

Pt

System

^Patient

Scale

Qn

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

Updated METHOD from CMS assessment to method-less since this is a general concept and not specific to CMS assessments.

Order vs. Observation

Observation

Member of these Panels

Related Names

• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey

Example Units

Related Codes

57203-2 Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?

Observation ID in Form

M0110

Form Context

Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?

Fully-Specified Name

Component

Episode Timing

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL774-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

85909-0 PATIENT HISTORY AND DIAGNOSES

Fully-Specified Name

Component

OASIS C2 - Patient history and diagnoses - start of care or resumption of care

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Hx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Patient Hx
• Pnl
• Report period
• Started
• Survey

57204-0 From which of the following Inpatient Facilities was the patient discharged within the past 14 days?

Observation ID in Form

M1000

Skip Logic

If NA, go to M1017.

Form Coding Instructions

Mark all that apply

Fully-Specified Name

Component

Inpatient discharge facility within the past 14D

Property

Type

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Changed TIME from Pt to 14D to reflect the term definition "within the past 14 days"; Added timing to the Component to follow LOINC convention

Order vs. Observation

Observation

Normative Answer List LL775-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Last
• Nominal
• Survey
• Typ

Related Codes

86470-2 Inpatient Discharge Date (most recent)

Observation ID in Form

M1005

Fully-Specified Name

Component

Most recent inpatient discharge date in the last 14D

Property

Date

Time

14D

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.63

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Past
• QNT
• Quan
• Quant
• Quantitative
• Survey

Example Units

Related Codes

46504-7 Inpatient Facility Diagnosis: ICD-10-CM Code

Term Description

Identifies diagnosis(es) for which patient was receiving treatment in an inpatient facility within the past 14 days. (Past 14 days encompasses the two-week period immediately preceding the start/resumption of care.)
Source: Regenstrief LOINC

Observation ID in Form

M1011a-M1011f

Form Coding Instructions

List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those conditions actively treated during an inpatient stay having a discharge date within the last 14 days (no V, W, X, Y, or Z codes or surgical codes). Omit "NA" option on SOC, ROC

Fully-Specified Name

Component

Inpatient stay within last 14D - ICD code

Property

Prid

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Change Reason

Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL3174-1

Externally Defined

Yes

Code System

ICD

Code System OID

1.3.6.1.4.1.12009.10.1.2055

Link to External List

http://www.cdc.gov/nchs/icd/icd10cm.htm

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Identity or presence
• International Classification of Diseases
• Nominal
• Past
• Survey

Related Codes

46507-0 Diagnosis Requiring Medical or Treatment Regimen Change Within Past 14 Days

Term Description

Identifies the diagnosis(es) that have caused an addition or change to the patient's treatment, regimen, health care services received, or medication within the past 14 days. (Past 14 days encompasses the two-week period immediately preceding the start/resumption of care [or the date of the follow-up/discharge visit].)
Source: Regenstrief LOINC

Observation ID in Form

M1017a-M0107f

Form Coding Instructions

Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days: List the patient's Medical Diagnoses and ICD-10-CM codes at the level of highest specificity for those conditions requiring changed medical or treatment regimen within the past 14 days (no V, W, X, Y, or Z codes or surgical codes)

Fully-Specified Name

Component

Regimen change in past 14D - ICD code

Property

Prid

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Change Reason

Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL3174-1

Externally Defined

Yes

Code System

ICD

Code System OID

1.3.6.1.4.1.12009.10.1.2055

Link to External List

http://www.cdc.gov/nchs/icd/icd10cm.htm

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Exchange
• Identity or presence
• International Classification of Diseases
• Last
• Nominal
• Replace
• Survey

Related Codes

86469-4 Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days

Observation ID in Form

M1018

Form Coding Instructions

If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions that existed prior to the inpatient stay or change in medical or treatment. (Mark all that apply.)

Fully-Specified Name

Component

Conditions prior to medical or treatment regimen change or inpatient stay that took place within past 14D

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Normative Answer List LL252-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Exchange
• Finding
• Findings
• Last
• Nominal
• Replace
• Report period
• Survey
• Tx

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

85911-6 Diagnoses, Symptom Control, and Optional Diagnoses

Observation ID in Form

M1021, M1023, M1025

Form Coding Instructions

List each diagnosis for which the patient is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2 (diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is no longer active (a resolved condition), then optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed. Diagnoses reported in M1025 will not impact payment

Fully-Specified Name

Component

Diagnoses, symptom control, and optional diagnoses

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey
• Sx

85912-4 Primary Diagnosis

Observation ID in Form

M1021

Form Coding Instructions

Column 1: Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided). Column 2: ICD-10-CM and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses. Column 3: May be completed if a Z-code is assigned to Column 2 and the underlying diagnosis is resolved. Column 4: Complete only if the Optional Diagnosis is a multiple coding situation (for example: a manifestation code)

Fully-Specified Name

Component

Primary diagnosis

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Dx
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

86255-7 Primary Diagnosis: ICD-10-code

Term Description

The condition that is the chief reason for providing care.
Source: Regenstrief LOINC

Observation ID in Form

M1021_A2_ICD

Form Coding Instructions

Column 1: Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided. Column 2: Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the underlying condition can often be entered in Column 2, as long as it is an active on-going condition impacting home health care

Fully-Specified Name

Component

Primary diagnosis ICD code

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Primary Dx ICD code

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.63

Last Updated

Version 2.73

Order vs. Observation

Both

Common Test Rank Get Info

17680

Normative Answer List LL3174-1

Externally Defined

Yes

Code System

ICD

Code System OID

1.3.6.1.4.1.12009.10.1.2055

Link to External List

http://www.cdc.gov/nchs/icd/icd10cm.htm

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• Dx
• Dx ICD code
• International Classification of Diseases
• Nominal
• Point in time
• Primary Dx ICD code
• Random
• Typ

Related Codes

85920-7 Primary Diagnosis Symptom Control Rating

Term Description

Assessment of the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider, the degree to which each condition limits daily activities, and if symptoms are controlled by current treatments.
Source: Regenstrief LOINC

Observation ID in Form

M1021_A2_Severity

Form Coding Instructions

Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis code is a V, W, X, Y or Z-code. Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide

Fully-Specified Name

Component

Symptom control rating

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Normative Answer List LL4489-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Sx

Related Codes

85914-0 Optional Diagnosis: ICD-10-CM

Term Description

An underlying condition for an on-going diagnosis that has already resolved. This does not include underlying conditions for an on-going diagnosis that is also on-going; that condition can be reported as a secondary or co-morbid diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1025_A3

Form Coding Instructions

Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment. Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when: a Z-code is reported in Column 2 AND the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated following a hysterectomy

Fully-Specified Name

Component

Underlying resolved condition ICD code

Property

Prid

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Normative Answer List LL3174-1

Externally Defined

Yes

Code System

ICD

Code System OID

1.3.6.1.4.1.12009.10.1.2055

Link to External List

http://www.cdc.gov/nchs/icd/icd10cm.htm

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Identity or presence
• International Classification of Diseases
• Nominal
• Report period
• Survey

Related Codes

86254-0 Optional Diagnosis: ICD-10-CM - multiple coding

Term Description

Additional codes for an underlying condition for an on-going diagnosis that has already resolved. For example, a manifestation code.
Source: Regenstrief LOINC

Observation ID in Form

M1025_B4 - M1025_F4

Form Coding Instructions

Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10- CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10- CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row

Fully-Specified Name

Component

Underlying resolved condition.multiple coding ICD code

Property

Prid

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Identity or presence
• International Classification of Diseases
• Mult
• Multi
• Nominal
• Report period
• Survey

Related Codes

85913-2 Other Diagnoses

Term Description

Other/secondary/additional diagnoses that impact a patient's health
Source: Regenstrief LOINC

Observation ID in Form

M1023

Form Coding Instructions

Column 1: Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided). Column 2: ICD-10-CM and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses. Column 3: May be completed if a Z-code is assigned to Column 2 and the underlying diagnosis is resolved. Column 4: Complete only if the Optional Diagnosis is a multiple coding situation (for example: a manifestation code)

Fully-Specified Name

Component

Other diagnoses

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Othr
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

81885-6 Other Diagnoses: ICD-10-CM

Observation ID in Form

M1023_B2_ICD-M1023_F2_ICD

Fully-Specified Name

Component

Diagnosis.secondary

Property

Imp

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Dx.secondary

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.56

Last Updated

Version 2.73

Order vs. Observation

Observation

Common Test Rank Get Info

11495

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• Dx
• Dx.secondary
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Nominal
• Point in time
• Random

Related Codes

85920-7 Other Diagnoses Symptom Control Rating

Term Description

Assessment of the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider, the degree to which each condition limits daily activities, and if symptoms are controlled by current treatments.
Source: Regenstrief LOINC

Observation ID in Form

M1023_B2_Severity - M1023_F2_Severity

Form Coding Instructions

Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis code is a V, W, X, Y or Z-code. Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide

Fully-Specified Name

Component

Symptom control rating

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Normative Answer List LL4489-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Sx

Related Codes

85914-0 Optional Diagnosis: ICD-10-CM

Term Description

An underlying condition for an on-going diagnosis that has already resolved. This does not include underlying conditions for an on-going diagnosis that is also on-going; that condition can be reported as a secondary or co-morbid diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1025_B3-M1025_F3

Form Coding Instructions

Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment. Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when: a Z-code is reported in Column 2 AND the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated following a hysterectomy

Fully-Specified Name

Component

Underlying resolved condition ICD code

Property

Prid

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Normative Answer List LL3174-1

Externally Defined

Yes

Code System

ICD

Code System OID

1.3.6.1.4.1.12009.10.1.2055

Link to External List

http://www.cdc.gov/nchs/icd/icd10cm.htm

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Identity or presence
• International Classification of Diseases
• Nominal
• Report period
• Survey

Related Codes

86254-0 Optional Diagnosis: ICD-10-CM - multiple coding

Term Description

Additional codes for an underlying condition for an on-going diagnosis that has already resolved. For example, a manifestation code.
Source: Regenstrief LOINC

Observation ID in Form

M1025_B4 - M1025_F4

Form Coding Instructions

Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10- CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10- CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row

Fully-Specified Name

Component

Underlying resolved condition.multiple coding ICD code

Property

Prid

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Identity or presence
• International Classification of Diseases
• Mult
• Multi
• Nominal
• Report period
• Survey

Related Codes

83243-6 Active Diagnoses-Comorbidities and Co-existing Conditions

Observation ID in Form

M1028

Form Coding Instructions

Check all that apply. See OASIS Guidance Manual for a complete list of relevant ICD-10 codes

Fully-Specified Name

Component

Comorbidities and coexisting conditions

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.72

Change Reason

Release 2.72: METHOD_TYP: Removed Method because this concept is not specific to only CMS Assessments.;

Order vs. Observation

Observation

Normative Answer List LL4493-4

Member of these Panels

Related Names

• Comorbid coexisting
• Finding
• Findings
• Nominal
• Point in time
• Random
• Survey

Related Codes

46466-9 Therapies the patient receives at home

Term Description

Identifies whether the patient is receiving intravenous, parenteral nutrition, or enteral nutrition therapy at home.
Source: Regenstrief LOINC

Observation ID in Form

M1030

Form Coding Instructions

Mark all that apply

Fully-Specified Name

Component

Therapeutic substance administered at home

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Added to the Component to clarify the concept

Order vs. Observation

Observation

Normative Answer List LL254-4

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Subs
• Survey
• Ther

Related Codes

57319-6 Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization?

Observation ID in Form

M1033

Form Coding Instructions

Mark all that apply

Fully-Specified Name

Component

Risk for hospitalization

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL4494-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Hospitalization hx
• Nominal
• Report period
• Survey

Related Codes

57206-5 Overall Status: Which description best fits the patient's overall status?

Observation ID in Form

M1034

Fully-Specified Name

Component

Overall status

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Changed Scale from Nom to Ord because the Answer List is ordinal

Order vs. Observation

Observation

Normative Answer List LL778-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

57207-3 Risk factors, either present or past, likely to affect health status and/or outcome

Observation ID in Form

M1036

Form Coding Instructions

Mark all that apply

Fully-Specified Name

Component

Risk factors affecting health status and or outcome

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "past or present" from the Component because that is implied

Order vs. Observation

Observation

Common Test Rank Get Info

16958

Normative Answer List LL779-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Risk factors present or past affecting health status and or outcome
• Survey

Related Codes

Third Party Copyright

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This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

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54567-3 Height and weight

Observation ID in Form

M1060

Form Coding Instructions

While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up

Fully-Specified Name

Component

Height and weight

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.74

Order vs. Observation

Order

Common Test Rank Get Info

295

Panel Type

Panel

Member of these Panels

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS
• Wt

Related Codes

3137-7 Height (in inches)

Observation ID in Form

M1060A

Form Coding Instructions

Record most recent height measure since the most recent SOC/ROC

Fully-Specified Name

Component

Body height

Property

Len

Time

Pt

System

^Patient

Scale

Qn

Method

Measured

Additional Names

Short Name

Body height Measured

Basic Attributes

Class

BDYHGT.ATOM

Type

Clinical

First Released

Version 1.0

Last Updated

Version 2.73

Order vs. Observation

Both

Common Test Rank Get Info

372

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Axial length
• bod
• Bodies
• BODY HEIGHT(LENGTH).ATOM
• Body length
• Length
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random

Example Units

Related Codes

3141-9 Weight (in pounds)

Observation ID in Form

M1060B

Form Coding Instructions

Base weight on most recent measure in last 30 days; measure weight consistently, according to standard facility practice (for example, in a.m. after voiding, before meal, with shoes off, etc.)

Fully-Specified Name

Component

Body weight

Property

Mass

Time

Pt

System

^Patient

Scale

Qn

Method

Measured

Additional Names

Short Name

Weight Measured

Basic Attributes

Class

BDYWGT.ATOM

Type

Clinical

First Released

Version 1.0

Last Updated

Version 2.73

Order vs. Observation

Both

Common Test Rank Get Info

115

Member of these Panels

Member of these Groups Get Info

Language Variants Get Info

Related Names

• Bdy weight
• bod
• Bodies
• BODY WEIGHT.ATOM
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Wt

Example Units

Related Codes

85951-2 Living Arrangements

Fully-Specified Name

Component

Living Arrangements

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Housing
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

85950-4 Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance?

Observation ID in Form

M1100

Form Context

Which of the following best describes the patient's residential circumstance and availability of assistance?

Form Coding Instructions

Check one box only

Fully-Specified Name

Component

Living situation and availability of assistance

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Observation

Normative Answer List LL4514-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

57042-4 SENSORY STATUS

Fully-Specified Name

Component

Sensory status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

57215-6 Vision (with corrective lenses if the patient usually wears them)

Observation ID in Form

M1200

Fully-Specified Name

Component

Vision

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL784-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

57216-4 Ability to Hear (with hearing aid or hearing appliance if normally used)

Observation ID in Form

M1210

Fully-Specified Name

Component

Ability to hear

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL785-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

57217-2 Understanding of Verbal Content in patient's own language (with hearing aid or device if used)

Observation ID in Form

M1220

Fully-Specified Name

Component

Understanding of verbal content

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL786-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

57218-0 Speech and Oral (Verbal) Expression of Language (in patient's own language)

Observation ID in Form

M1230

Fully-Specified Name

Component

Speech and oral expression of language

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL787-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

57219-8 Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient's ability to communicate the severity of pain)?

Observation ID in Form

M1240

Fully-Specified Name

Component

Formal pain assessment using standardized tool

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL788-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

57220-6 Frequency of pain interfering with patient's activity or movement

Observation ID in Form

M1242

Fully-Specified Name

Component

Frequency of pain interfering with activity or movement

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed Property to NRat because this is a frequency term; Changed Property from NRat to Find because the answer list does not reflect Nrat

Order vs. Observation

Observation

Normative Answer List LL789-9

Member of these Panels

Related Names

• Activ
• Actvty
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Movements
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

85917-3 INTEGUMENTARY STATUS

Fully-Specified Name

Component

OASIS C2 - Integumentary status - start of care or resumption of care

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels