52534-5 Principal Diagnosis

Observation ID in Form

A

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

Indicate the principal diagnosis for billing purposes. Indicate the ICD-9 CM code. For V-codes, also indicate the medical diagnosis and associated ICD-9 CM code. Be as specific as possible

Fully-Specified Name

Component

Principal Diagnosis

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.73

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Dx
• Point in time
• Random
• Survey

46584-9 ICD-9 CM for Principal Diagnosis at Assessment

Term Description

A case mix diagnosis is a primary diagnosis that assigns patients with selected conditions to an orthopedic, diabetes, neurological, or burns/trauma group for Medicare PPS case mix adjustment. A case mix diagnosis may involve manifestation coding.
Source: Regenstrief LOINC

Observation ID in Form

A1

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Payment diagnosis - primary ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Dx
• Dx.primary
• Identity or presence
• International Classification of Diseases
• Nominal
• Outcome and assessment information set
• Payment Dx
• Payment Dx- primary ICD code
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

86255-7 Primary diagnosis ICD code

Term Description

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

Observation ID in Form

A2

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

Example Answer List LL4547-7

Externally Defined

Yes

Code System

Code System OID

1.3.6.1.4.1.12009.10.1.3459

Link to External List

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

18630-4 Primary Diagnosis at Assessment

Observation ID in Form

A1a

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

Basic Attributes

Class

ATTACH.REHAB

Type

Claims Attachments

First Released

Version 1.0l

Last Updated

Version 2.70

Change Reason

Release 2.70: AnswerListId: Added example answer list;

Order vs. Observation

Observation

Example Answer List LL4747-3

Member of these Panels

Language Variants Get Info

Related Names

• ATTACH
• ATTACH.REHAB
• Dx
• Dx.primary
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Nominal
• Point in time
• Random

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.

29308-4 Diagnosis

Part Descriptions

LP72437-4   Diagnosis
The end result of a diagnostic process that identifies a disease. Source: Regenstrief LOINC

Observation ID in Form

A2a

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Diagnosis

Property

Imp

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Dx

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.73

Order vs. Observation

Observation

Common Test Rank Get Info

4809

Member of these Panels

Language Variants Get Info

Related Names

• Dx
• H+P
• H+P.PX
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Nominal
• P prime
• Point in time
• Random

Related Codes

52807-5 Other Diagnoses, Comorbidities, and Complications

Observation ID in Form

B

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

List other diagnoses being treated, managed, or monitored in this setting. Include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition)

Form Coding Instructions

List up to 15 ICD-9 CM codes and associated diagnoses being treated, managed, or monitored in this setting. Include all diagnoses ( e.g. depression, schizophrenia, dementia, protein calorie malnutrition). If a V-code is listed, also provide the ICD-9 CM code for the medical diagnosis being treated

Fully-Specified Name

Component

Medical Coding Other Diagnoses, Comorbidities, and Complications

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Othr
• Point in time
• Random
• Survey

52797-8 Diagnosis ICD code [Identifier]

Observation ID in Form

B1a

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Diagnosis ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Dx ICD code

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.26

Last Updated

Version 2.73

Change Reason

Changed CLASS from SURVEY.MDS to CLIN

Order vs. Observation

Both

Common Test Rank Get Info

743

Example Answer List LL4547-7

Externally Defined

Yes

Code System

Code System OID

1.3.6.1.4.1.12009.10.1.3459

Link to External List

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

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• Dx
• Dx ICD code
• Identity or presence
• International Classification of Diseases
• Nominal
• Point in time
• Random

Related Codes

29308-4 Diagnosis

Part Descriptions

LP72437-4   Diagnosis
The end result of a diagnostic process that identifies a disease. Source: Regenstrief LOINC

Observation ID in Form

B1b

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Diagnosis

Property

Imp

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Dx

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.73

Order vs. Observation

Observation

Common Test Rank Get Info

4809

Member of these Panels

Language Variants Get Info

Related Names

• Dx
• H+P
• H+P.PX
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Nominal
• P prime
• Point in time
• Random

Related Codes

52808-3 Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)

Observation ID in Form

C

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Medical Coding Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Surg
• Survey
• Ther

52558-4 Did the patient have one or more major procedures (e.g., G-tube placement, EEG, abdominal, cat scans; do not include x-rays, EKGs, ultrasounds) during this admission?

Observation ID in Form

C1

Type of Entry

Question expects user entry - requires response [Q]

Skip Logic

If No, skip to Section X.

Form Coding Instructions

List up to 15 procedures (diagnostic, surgical and therapeutic interventions). Indicate if a procedure was left, right, or not applicable (N/A). If procedure was bilateral (e.g., bilateral knee replacement), check both left and right boxes

Fully-Specified Name

Component

Procedure this admission

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Survey Question

Text

Did the patient have one or more major procedures (e.g., G-tube placement, EEG, abdominal, cat scans; do not include x-rays, EKGs, ultrasounds) during this admission?

Source

CARE I.c01

Normative Answer List LL251-0

Member of these Panels

Related Names

• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

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.

69967-8 Procedure ICD code

Term Description

Diagnostic, surgical and therapeutic interventions
Source: Regenstrief LOINC

Observation ID in Form

C2a

Fully-Specified Name

Component

Procedure ICD code

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.42

Member of these Panels

Related Names

• CARE Survey
• Finding
• Findings
• International Classification of Diseases
• Nominal
• Point in time
• Random
• Survey

29300-1 Procedure

Observation ID in Form

C2b

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Procedure

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Procedure type

Basic Attributes

Class

H&P.PX

Type

Clinical

First Released

Version 2.03

Last Updated

Version 2.73

Common Test Rank Get Info

2979

Member of these Panels

Language Variants Get Info

Related Names

• H+P
• H+P.PX
• Nominal
• P prime
• Point in time
• Random
• Typ