Form Coding Instructions

Indicate the primary diagnosis and up to 14 other diagnoses being treated, managed, or monitored in this setting. Please include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition)

Source: Centers for Medicare & Medicaid Services

18630-4 Primary Diagnosis at Assessment

Observation ID in Form

A1

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis.primary
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Long Common Name

Primary diagnosis

Basic Attributes

Class
ATTACH.REHAB
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.70 (MIN)
Change Reason
Release 2.70: AnswerListId: Added example answer list;
Order vs. Observation
Observation

Example Answer List LL4747-3

AnswerCodeScoreAnswer ID
OtherLA46-8
AlcoholismLA20350-7
Bleeding disorderLA20352-3
Currently receiving chemotherapy for cancerLA20353-1
Congenital anomaliesLA20354-9
Congestive heart failure (CHF)LA12740-9
Current smokerLA20356-4
Chronic renal failureLA20357-2
Cerebrovascular accidentLA22244-0
Diabetes mellitusLA14291-1
Disseminated cancerLA20360-6
Advanced directive limiting careLA20361-4
Functionally dependent health statusLA20363-0
HypertensionLA7444-8
PrematurityLA20368-9
Chronic obstructive pulmonary diseaseLA28200-6
Steroid useLA20370-5
CirrhosisLA9639-1
DementiaLA20372-1
Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD)LA28412-7
Anticoagulant therapyLA28199-0
Angina pectoris Copyright http://snomed.info/sct ID:194828000 Angina (disorder)LA14275-4
Mental/personality disorderLA28198-2
Myocardial infarction Copyright http://snomed.info/sct ID:22298006 Myocardial infarction (disorder)LA14274-7
Peripheral arterial disease Copyright http://snomed.info/sct ID:399957001 Peripheral arterial occlusive disease (disorder)LA28197-4
Substance abuse disorder Copyright http://snomed.info/sct ID:66214007 Substance abuse (disorder)LA28195-8

Member of these Panels

LOINCLong Common Name
76464-7American Physical Therapy Association registry panel
52747-3Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
97782-7Spine Tango Surgery 2017

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Διάγνωση.κύρια:Imp:Pt:^Ασθενής:Nom:
Synonyms: - ATTACH ATTACH.REHAB Imp Nom Pt Ασθενής Διάγνωση Διάγνωση.κύρια
es-ARSpanish (Argentina)diagnóstico.primario:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
it-ITItalian (Italy)Diagnosi.primaria:Imp:Pt:^Paziente:Nom:
Synonyms: Allegato Allegato riabilitazione Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
ru-RURussian (Russian Federation)Диагноз.основной:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
zh-CNChinese (China)诊断.主要:印象:时间点:^患者:名义型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.康复治疗;健康保险便携与责任法案信息附件.康复;健康保险便携与责任法案信息附件.康复治疗;康复信息附件;康复治疗HIPAA信息附件;康复治疗信息附件;康复治疗健康保险便携与责任法 主要诊断 信息附件;健康保险便携与责任法案信息附件;附件 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述,始终是对其他某种观察指标的解释或抽象(一系列检验项目结果、一幅图像或者整个某位病人),而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 时刻;随机;随意;瞬间 诊断结论;判断;结论