57040-8 Clinical Record Items during assessment period [CMS Assessment]

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

Skip Logic

If Yes to "4 - Recertification (follow-up reassessment" , then go to M0110. If Yes to "5 - Other follow-up", then go to M0110. If Yes to "6 - Transferred to an inpatient facility - patient not discharged from agency", then go to M1040. If Yes to"7 - Transferred to an inpatient facility - patient discharged from agency", then go to M1040. If "Yes to 8 - Death at home", then go to M0903. If " Yes to 9 - Discharge from agency", then go to M1040.

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) during assessment period [CMS Assessment]

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

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

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.

69327-5 Patient history and diagnosis

Fully-Specified Name

Component

Patient history and diagnosis - follow-up

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.38

Last Updated

Version 2.73

Change Reason

Release 2.73: Status: LOINC will keep most current version and one prior version of CMS assessments active and discourage all older versions.;

Panel Type

Panel

Member of these Panels

Related Names

• Dx
• Hx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Patient Hx
• Patient hx & Dx - follow-up
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

46609-4 Diagnosis and severity index

Form Coding Instructions

(M1020/1022/1024) Diagnoses, Symptom Control, and Payment Diagnoses: List each diagnosis for which the patient is receiving home care (Column 1) and enter its ICD-9-C M code at the level of highest specificity (no surgical/procedure codes) (Column 2). Diagnoses are listed in the order that best reflect the seriousness of each condition and support the disciplines and services provided. Rate the degree of symptom control for each condition (Column 2). Choose one value that represents the degree of symptom control appropriate for each diagnosis: V-codes (for M1020 or M1022) or E-codes (for M1022 only) may be used. ICD-9-C M sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a V-code is reported in place of a case mix diagnosis, then optional item M1024 Payment Diagnoses (Columns 3 and 4) may be completed. A case mix diagnosis is a diagnosis that determines the Medicare P P S case mix group. Do not assign symptom control ratings for V- or E-codes. Code each row according to the following directions for each column: Column 1: Enter the description of the diagnosis.Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided.) Column 2: Enter the ICD-9-C M code for the diagnosis described in Column 1; Rate the degree of symptom control for the condition listed in Column 1 using the following scale: 0 - Asymptomatic, no treatment needed at this time 1 - Symptoms well controlled with current therapy 2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring 3 - Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring 4 - Symptoms poorly controlled; history of re-hospitalizations Note that in Column 2 the rating for symptom control of each diagnosis should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided.ICD-9-C M and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of Column 3: (OPTIONAL) If a V-code is assigned to any row in Column 2, in place of a case mix diagnosis, it may be necessary to complete optional item M1024 Payment Diagnoses (Columns 3 and 4). See OASIS-C Guidance Manual.Complete if a V-code is assigned under certain circumstances to Column 2 in place of a case mix diagnosis. Column 4: (OPTIONAL) If a V-code in Column 2 is reported in place of a case mix diagnosis that requires multiple diagnosis codes under ICD-9-C M coding guidelines, enter the diagnosis descriptions and the ICD-9-C M codes in the same row in Columns 3 and 4. For example, if the case mix diagnosis is a manifestation code, record the diagnosis description and ICD-9-C M code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-9-C M code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.Complete only if the V-code in Column 2 is reported in place of a case mix diagnosis that is a multiple coding situation (e.g., a manifestation code)

Fully-Specified Name

Component

Diagnosis and severity index

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.73

Panel Type

Panel

Member of these Panels

Related Names

• Dx
• Dx and severity index
• Outcome and assessment information set
• 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

Fully-Specified Name

Component

Primary diagnosis ICD code

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Panel Name

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

46512-0 Primary Diagnosis Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1020

Fully-Specified Name

Component

Primary diagnosis severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.50

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• Ordinal
• Outcome and assessment information set
• Point in time
• Primary Dx severity rating
• Ql
• Qual
• Qualitative
• Random
• Screen
• 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.

46513-8 Other diagnosis 1 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 1 - 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
• i
• Identity or presence
• International Classification of Diseases
• Nominal
• Other Dx 1- ICD code
• Othr
• Outcome and assessment information set
• 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.

46514-6 Other diagnosis 1: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 1 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• i
• Ordinal
• Other Dx 1- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• 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.

46515-3 Other diagnosis 2 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 2 - 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
• Identity or presence
• II
• International Classification of Diseases
• Nominal
• Other Dx 2- ICD code
• Othr
• Outcome and assessment information set
• 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.

46516-1 Other diagnosis 2: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Other diagnosis 2 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• II
• Ordinal
• Other Dx 2- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• 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.

46517-9 Other diagnosis 3 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 3 - 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
• Identity or presence
• III
• International Classification of Diseases
• Nominal
• Other Dx 3- ICD code
• Othr
• Outcome and assessment information set
• 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.

46518-7 Other diagnosis 3: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 3 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• III
• Ordinal
• Other Dx 3- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• 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.

46519-5 Other diagnosis 4 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 4 - 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
• Identity or presence
• International Classification of Diseases
• Nominal
• Other Dx 4- ICD code
• Othr
• Outcome and assessment information set
• 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.

46520-3 Other diagnosis 4: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 4 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• Ordinal
• Other Dx 4- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• 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.

46521-1 Other diagnosis 5 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 5 - 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
• Identity or presence
• International Classification of Diseases
• Nominal
• Other Dx 5- ICD code
• Othr
• Outcome and assessment information set
• 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.

46522-9 Other diagnosis 5: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 5 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• Ordinal
• Other Dx 5- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• 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.

58051-4 Payment diagnosis [OASIS-C]

Observation Required in Panel

Required

Fully-Specified Name

Component

Payment diagnosis

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Panel Type

Panel

Member of these Panels

Related Names

• Dx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Payment Dx
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

49561-4 Payment diagnosis [identifier]

Observation ID in Form

M1024

Observation Required in Panel

Required

Fully-Specified Name

Component

Payment diagnosis

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Panel Name

Short Name

Payment Dx

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.22

Last Updated

Version 2.40

Example 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

Language Variants Get Info

Related Names

• CLIN
• Dx
• Identity or presence
• Nominal
• Payment Dx
• Point in time
• Random

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

Therapies are patient receives at home: (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

57042-4 Sensory status during assessment period [CMS Assessment]

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

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)

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 expression of language during assessment period [CMS Assessment]

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)?

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

57044-0 Integumentary status

Fully-Specified Name

Component

Integumentary status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Panel Type

Panel

Member of these Panels

Related Names

• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

57307-1 Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"

Observation ID in Form

M1306

Skip Logic

If "0 - No", then go to M1322.

Fully-Specified Name

Component

Unhealed pressure injury at Stage 2 or higher or designated as unstageable

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS-C

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.64

Change Reason

"Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Survey Question

Text

Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"

Source

OASIS-C.M1306

Normative Answer List LL251-0

Member of these Panels

Related Names

• Arterial Stenosis
• Finding
• Findings
• II
• Nominal
• Outcome and assessment information set
• Point in time
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Survey.OASIS
• Ulcer

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.

58102-5 Current number of unhealed (non-epithelialized) pressure ulcers at each stage

Observation ID in Form

M1308

Form Coding Instructions

Enter "0" if none; excludes Stage I pressure ulcers

Fully-Specified Name

Component

Current number of unhealed (non-epithelialized) pressure injuries at each stage

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• No
• Num
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Survey.OASIS

57186-9 Number currently present

Observation ID in Form

M1308.1

Form Coding Instructions

Column 1 Complete at SOC/ROC/FU & D/C

Fully-Specified Name

Component

Number of pressure injuries at each stage

Property

-

Time

Pt

System

^Patient

Scale

Set

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• No
• Num
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Survey.OASIS

55124-2 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister

Term Description

A stage 2 pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1a

Form Context

Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister

Fully-Specified Name

Component

Number of pressure injuries - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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 MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

55125-9 Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Term Description

A stage 3 pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1800.1b

Skip Logic

If 0, skip to M0400C, Stage 4.

Form Context

Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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 MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• III
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

55126-7 Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Term Description

A stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1c

Form Context

Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 4

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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 MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54893-3 Unstageable: Known or likely but unstageable due to non-removable dressing or device

Term Description

A pressure ulcer that is unstageable due to a non-removable dressing is defined as a known pressure ulcer that is covered by a non-removable dressing or device, such as a surgical dressing, cast, other orthopedic device, or dressing not to be removed per physician's order.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1d1

Description

Unstageable: Known or likely but unstageable due to non-removable dressing or device

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to non-removable dressing or device

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt".; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54946-9 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.

Term Description

Slough tissue is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Eschar tissue is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1d2

Description

Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt";Updated COMPONENT from "and or" to "&or" to match convention; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54950-1 Unstageable: Suspected deep tissue injury in evolution

Term Description

A pressure ulcer that is unstageable due to deep tissue injury has purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1d3

Form Context

Unstageable: Suspected deep tissue injury in evolution

Fully-Specified Name

Component

Number of pressure injuries - unstageable with suspected deep tissue injury in evolution

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt"; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels