83251-9 Hearing, Speech, and Vision

Observation ID in Form

B

Fully-Specified Name

Component

IRF-PAI - Hearing, speech, and vision - admission

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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

Related Codes

83250-1 Expression of Ideas and Wants

Observation ID in Form

BB0700

Form Context

Consider both verbal and non-verbal expression and excluding language barriers

Form Coding Instructions

(3-day assessment period)

Fully-Specified Name

Component

Expression of ideas and wants during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4144-3

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83249-3 Understanding Verbal Content (with hearing aid or device, if used and excluding language barriers)

Observation ID in Form

BB0800

Form Context

Consider both verbal and non-verbal expression and excluding language barriers

Form Context

With hearing aid or device, if used, and excluding language barriers

Form Coding Instructions

(3-day assessment period)

Fully-Specified Name

Component

Understanding verbal content during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4145-0

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey
• Understand verbal

Related Codes

83267-5 Cognitive Patterns

Observation ID in Form

C

Fully-Specified Name

Component

IRF-PAI - Cognitive patterns - admission

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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

Related Codes

83248-5 Should Brief Interview for Mental Status (C0200-C0500) be conducted?

Observation ID in Form

C0100

Skip Logic

If 0, skip to C0900. Memory/Recall Ability. If 1, continue to C0200. Repetition of Three Words.

Form Coding Instructions

Attempt to conduct interview with all patients

Fully-Specified Name

Component

Should brief interview for mental status be conducted during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.66

Order vs. Observation

Observation

Normative Answer List LL4485-0

Member of these Panels

Related Names

• 3 days
• BIMS
• BIMS conducted
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• 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.

52491-8 Brief Interview for Mental Status

Fully-Specified Name

Component

Brief interview for mental status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.BIMS

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.67

Change Reason

Removed (BIMS) since included in LNC override; Added Method of BIMS to include across CMS panels

Order vs. Observation

Both

Panel Type

Panel

Member of these Panels

Related Names

• Brief Interview for Mental Status (BIMS) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52731-7 Repetition of Three Words. Number of words repeated by patient after first attempt

Observation ID in Form

C0200

Form Coding Instructions

After the patient's first attempt say: "I will repeat each of the three words with a cue and ask you about them later: sock, something to wear; blue, a color; bed, a piece of furniture." You may repeat the words up to two more times

Form Coding Instructions

Ask patient: "I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words."

Fully-Specified Name

Component

Repetition of three words

Property

Num

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to make consistent with other survey methods; Changed property to Num to match answer list

Order vs. Observation

Observation

Normative Answer List LL687-5

Member of these Panels

Related Names

• 3
• Brief Interview for Mental Status
• Cnt
• Count
• Number
• 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.

54510-3 Temporal Orientation: Year, Month, and Day

Observation ID in Form

C0300

Fully-Specified Name

Component

Temporal orientation (orientation to year, month, and day)

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

Change Reason

Removed MDSv3 from component and added method of BIMS so that term can be used across CMS panels.; Changed Class from SURVEY.MDS to PANEL.SURVEY.CMS

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Temporal orientation (orientation to year, month, and day) - MDSv3

52732-5 Please tell me what year it is right now

Observation ID in Form

C0300A

Form Coding Instructions

Ask patient: "Please tell me what year it is right now."

Fully-Specified Name

Component

Temporal orientation - current year

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Order vs. Observation

Observation

Normative Answer List LL560-4

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52733-3 What month are we in right now?

Observation ID in Form

C0300B

Form Coding Instructions

Ask patient: "What month are we in right now?"

Fully-Specified Name

Component

Temporal orientation - current month

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow convention of other survey terms

Order vs. Observation

Observation

Normative Answer List LL644-6

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

54609-3 What day of the week is today?

Observation ID in Form

C0300C

Form Coding Instructions

Ask patient: "What day of the week is today?"

Fully-Specified Name

Component

Temporal orientation - current day of the week

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." and ".MDS" from method to follow convention of other survey terms and to include term across CMS assessments

Order vs. Observation

Observation

Normative Answer List LL645-3

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52493-4 Recall

Observation ID in Form

C0400

Form Coding Instructions

Ask patient: "Let's go back to the first question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (i.e. something to wear; a color; a piece of furniture) for that word

Fully-Specified Name

Component

Recall

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.BIMS

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.67

Change Reason

Added method of BIMS

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Brief Interview for Mental Status (BIMS) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52735-8 Recalls "sock"?

Observation ID in Form

C0400A

Fully-Specified Name

Component

Recall - sock

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL646-1

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52736-6 Recalls "blue"?

Observation ID in Form

C0400B

Fully-Specified Name

Component

Recall - blue

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL647-9

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52737-4 Recalls "bed"?

Observation ID in Form

C0400C

Fully-Specified Name

Component

Recall - bed

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL648-7

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

54614-3 BIMS Summary Score

Observation ID in Form

C0500

Form Coding Instructions

Add scores for each question C0200-C0400 and fill in total score (00-15). Enter 99 if the patient was unable to complete interview

Fully-Specified Name

Component

Brief interview for mental status - summary score

Property

Score

Time

Pt

System

^Patient

Scale

Qn

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Changed method to BIMS so term can be used across CMS assessments; Updated CLASS to SURVEY.CMS; Removed (BIMS) from Component because it is repeated in the Method

Order vs. Observation

Observation

Member of these Panels

Related Names

• BIMS summary score
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Scale
• Survey

Example Units

54615-0 Should the Staff Assessment for Mental Status (C0900) be Conducted?

Observation ID in Form

C0600

Skip Logic

If 0, skip to GG0100. Prior Functioning: Everyday Activities. If 1, continue to C0900. Memory/Recall Ability.

Fully-Specified Name

Component

Should staff assessment for mental status be conducted

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

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; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL4180-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Staff assessment for mental status should be conducted
• Survey

Related Codes

83241-0 Staff Assessment for Mental Status

Skip Logic

Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed

Fully-Specified Name

Component

CMS - Staff assessment for mental status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Additional Names

Display Name

CMS - Staff assessment for mental status [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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; Release 2.75: COMPONENT: new policy for subset organizers - use existing codes irrespective of having different children;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

83240-2 Memory/Recall Ability

Observation ID in Form

C0900

Form Coding Instructions

Check all that the patient was normally able to recall

Fully-Specified Name

Component

Memory &or recall ability

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL4150-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Memory/recall ability
• Nominal
• Point in time
• Random
• Survey

Related Codes

83268-3 Functional Abilities and Goals - Admission

Observation ID in Form

GG

Fully-Specified Name

Component

IRF-PAI - Functional abilities and goals - admission

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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

Related Codes

83239-4 Prior Functioning: Everyday Activities

Observation ID in Form

GG0100

Form Coding Instructions

Indicate the patient's usual ability with everyday activities prior to the current illness, exacerbation, or injury

Fully-Specified Name

Component

IRF-PAI v3.0, MDS v1.17.1, 1.17.2, OASIS E - Prior functioning: everyday activities

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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; Release 2.72: COMPONENT: Updated to include current version of OASIS that uses this panel; Release 2.69: COMPONENT: Updated to state the current active versions of each form that use this panel.; Previous Releases: Removed "IRF-PAI" from Component because this panel is used in both the IRF-PAI and OASIS

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

85070-1 Self-Care

Term Description

Need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury.
Source: Regenstrief LOINC

Observation ID in Form

GG0100A

Form Coding Instructions

Code the patient's need for assistance with bathing, dressing, using the toilet, and eating prior to the current illness, exacerbation, or injury

Fully-Specified Name

Component

Prior functioning.self care

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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: Change Component display to match Component, like similar terms

Order vs. Observation

Observation

Normative Answer List LL4309-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Self-care
• 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.

85071-9 Indoor Mobility (Ambulation)

Term Description

Need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.
Source: Regenstrief LOINC

Observation ID in Form

GG0100B

Form Coding Instructions

Code the patient's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury

Fully-Specified Name

Component

Prior functioning.indoor mobility-ambulation

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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 LL4309-2

Member of these Panels

Related Names

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

Related Codes

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.

85072-7 Stairs

Term Description

Need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.
Source: Regenstrief LOINC

Observation ID in Form

GG0100C

Form Coding Instructions

Code the patient's need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury

Fully-Specified Name

Component

Prior functioning.stairs

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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 LL4309-2

Member of these Panels

Related Names

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

Related Codes

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.

85073-5 Functional Cognition

Term Description

Need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.
Source: Regenstrief LOINC

Observation ID in Form

GG0100D

Form Coding Instructions

Code the patient's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury

Fully-Specified Name

Component

Prior functioning.functional cognition

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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 LL4309-2

Member of these Panels

Related Names

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

Related Codes

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.

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83234-5 Prior Device Use

Term Description

Devices and aids used by the patient prior to the current illness, exacerbation, or injury.
Source: Regenstrief LOINC

Observation ID in Form

GG0110

Form Coding Instructions

Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury. Check all that apply

Fully-Specified Name

Component

Prior device use

Property

Type

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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 LL4152-6

Member of these Panels

Related Names

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

Related Codes

83233-7 Self-Care - Admission Performance

Observation ID in Form

GG0130_1

Form Coding Instructions

Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at admission, code the reason. Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Fully-Specified Name

Component

Self-care - admission performance

Property

-

Time

3D

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.67

Change Reason

Removed IRF-PAI from Component because term is used in IRF-PAI, OASIS, and MDS assessments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

83232-9 Eating

Term Description

The patient's usual ability to use suitable utensils to bring food/liquid to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.
Source: Regenstrief LOINC

Observation ID in Form

GG0130A1

Form Context

The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency

Fully-Specified Name

Component

Eating - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.63

Change Reason

Added "/liquid" to Term Definition

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Eating ability
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83230-3 Oral hygiene

Term Description

The patient's usual ability to use suitable items to clean teeth. If patient wears dentures, the ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.
Source: Regenstrief LOINC

Observation ID in Form

GG0130B1

Form Context

The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.]

Fully-Specified Name

Component

Oral hygiene - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Oral hygiene ability
• Ordinal
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83228-7 Toileting hygiene

Term Description

The patient's usual ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan or urinal. If managing an ostomy, include wiping the opening but not managing equipment.
Source: Regenstrief LOINC

Observation ID in Form

GG0130C1

Form Context

The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan or urinal. If managing an ostomy, include wiping the opening but not managing equipment

Fully-Specified Name

Component

Toileting hygiene - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey
• Toileting ability

Related Codes

83226-1 Shower/bathe self

Term Description

The patient's usual ability to bathe self in shower or tub, including washing, rinsing, and drying self. Does not include transferring in/out of tub/shower.
Source: Regenstrief LOINC

Observation ID in Form

GG0130E1

Form Context

The ability to bathe self in shower or tub, including washing, rinsing, and drying self. Does not include transferring in/out of tub/shower

Fully-Specified Name

Component

Shower &or bathe self - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• Bathe ability
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83224-6 Upper body dressing

Term Description

The patient's usual ability to put on and remove shirt or pajama top; includes buttoning, if applicable.
Source: Regenstrief LOINC

Observation ID in Form

GG0130F1

Form Context

The ability to put on and remove shirt or pajama top; includes buttoning, if applicable

Fully-Specified Name

Component

Upper body dressing - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• bod
• Bodies
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey
• Up
• Upper dressing ability

Related Codes

83222-0 Lower body dressing

Term Description

The patient's usual ability to dress and undress below the waist, including fasteners; does not include footwear.
Source: Regenstrief LOINC

Observation ID in Form

GG0130G1

Form Context

The ability to dress and undress below the waist, including fasteners; does not include footwear

Fully-Specified Name

Component

Lower body dressing - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• bod
• Bodies
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Low
• Lower dressing ability
• Ordinal
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83220-4 Putting on/taking off footwear

Term Description

The patient's usual ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility.
Source: Regenstrief LOINC

Observation ID in Form

GG0130H1

Form Context

The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility

Fully-Specified Name

Component

Putting on and taking off footwear - functional ability during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4153-4

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Footwear ability
• Ordinal
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

85054-5 Self-Care - Discharge Goal

Observation ID in Form

GG0130_2

Form Coding Instructions

Code the patient's discharge goal using the 6-point scale. Do not use codes 07, 09, or 88 to code discharge goal(s). Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or poor quality, score according to amount of assisance provided. Activities may be completed with or without assistive devices

Form Coding Instructions

(Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B.) Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Do not use codes 07, 09, or 88 to code end of SNF PPS stay (discharge) goals

Fully-Specified Name

Component

Self-care - discharge goal

Property

-

Time

3D

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.67

Change Reason

Removed IRF-PAI from Component because term is used across IRF-PAI, OASIS, and MDS assessments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Disch
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Survey

Related Codes

83231-1 Eating

Term Description

Expected functional performance for the patient's ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.
Source: Regenstrief LOINC

Observation ID in Form

GG0130A2

Form Context

The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency

Fully-Specified Name

Component

Eating - functional goal recorded during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4154-2

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Eating goal
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83229-5 Oral hygiene

Term Description

Expected functional performance for the patient's ability to use suitable items to clean teeth. If patient wears dentures, the ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.
Source: Regenstrief LOINC

Observation ID in Form

GG0130B2

Form Context

The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.]

Fully-Specified Name

Component

Oral hygiene - functional goal recorded during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4154-2

Member of these Panels

Related Names

• 3 days
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Oral hygiene goal
• Ordinal
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

83227-9 Toileting hygiene

Term Description

Expected functional performance for the patient's ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan or urinal. If managing an ostomy, include wiping the opening but not managing equipment.
Source: Regenstrief LOINC

Observation ID in Form

GG0130C2

Form Context

The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan or urinal. If managing an ostomy, include wiping the opening but not managing equipment

Fully-Specified Name

Component

Toileting hygiene - functional goal recorded during 3D assessment period

Property

Find

Time

3D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL4154-2

Member of these Panels