Version 2.78

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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1

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

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57192-7 Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up
57191-9 Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86244-1 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
86189-8 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Código ICD de diagnóstico primario:Tipo:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Diagnosi primaria codice ICD:Tipo:Pt:^Paziente:Nom:
Synonyms: Clinico paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 主要诊断 ICD 代码:类型:时间点:^患者:名义型:
Synonyms: ICD 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 国际疾病分类（International Classification of Diseases，ICD） 国际疾病分类;international Classification of diseases;ICD 国际疾病分类法 国际疾病分类系统 型 时刻;随机;随意;瞬间 诊断 ICD 编码;ICD 诊断代码;ICD 诊断编码;国际疾病分类;international Classification of diseases;ICD 诊断结论;判断;结论

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

Answer Code Score Answer ID
Other LA46-8
Alcoholism LA20350-7
Bleeding disorder LA20352-3
Currently receiving chemotherapy for cancer LA20353-1
Congenital anomalies LA20354-9
Congestive heart failure (CHF) LA12740-9
Current smoker LA20356-4
Chronic renal failure LA20357-2
Cerebrovascular accident LA22244-0
Diabetes mellitus LA14291-1
Disseminated cancer LA20360-6
Advanced directive limiting care LA20361-4
Functionally dependent health status LA20363-0
Hypertension LA7444-8
Prematurity LA20368-9
Chronic obstructive pulmonary disease LA28200-6
Steroid use LA20370-5
Cirrhosis LA9639-1
Dementia LA20372-1
Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD) LA28412-7
Anticoagulant therapy LA28199-0
Angina pectoris Copyright http://snomed.info/sct ID:194828000 Angina (disorder) LA14275-4
Mental/personality disorder LA28198-2
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

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

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) diagnóstico.primario:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Diagnosi.primaria:Imp:Pt:^Paziente:Nom:
Synonyms: Allegato Allegato riabilitazione Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Диагноз.основной:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (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

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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
74293-2 Oncology plan of care and summary - recommended CDA set
93149-3 PhenX - bone age protocol 220301
62863-6 PhenX domain - Infectious diseases and immunity
62896-6 PhenX domain - Skin, bone, muscle and joint

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Diagnose:Interpretation:Zeitpunkt:^Patient:Nominal:
es-ES Spanish (Spain) Diagnóstico:Impresión/interpretación del estudio:Punto temporal:^paciente:Nom:
es-MX Spanish (Mexico) Diagnóstico:Interpretación:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) diagnóstico:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
fr-CA French (Canada) Diagnostic:Impression:Temps ponctuel:^Patient:Nominal:
fr-BE French (Belgium) Diagnostic:Impression/interprétation d'étude:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Diagnosi:Imp:Pt:^Paziente:Nom:
Synonyms: Esame obbiettivo Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Diagnóstico:Imp:Pt:^Paciente:Nom:
Synonyms: ; Dx; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Диагноз:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
uk-UA Ukrainian (Ukraine) Діагноз:Інтерпретація:МоментЧасу:^Пацієнт:Категорійно:
Synonyms: Dx; H+P; H+P.PX; Impression; Impression/interpretation of study; Impressions; Interp; Interpretation; Nominal; P prime; Point in time; Random
zh-CN Chinese (China) 诊断:印象:时间点:^患者:名义型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 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 历史纪录与体格检查 历史纪录与体格检查小节 时刻;随机;随意;瞬间 病史与体格检查 诊断结论;判断;结论