85911-6
Diagnoses, Symptom Control, and Optional Diagnoses
Active
85912-4 Primary Diagnosis
Observation ID in Form
M1021
Form Coding Instructions
Column 1: Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided). Column 2: ICD-10-CM and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses. Column 3: May be completed if a Z-code is assigned to Column 2 and the underlying diagnosis is resolved. Column 4: Complete only if the Optional Diagnosis is a multiple coding situation (for example: a manifestation code)
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Primary diagnosis
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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
| LOINC | Long Common Name |
|---|---|
| 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] |
86255-7 Primary Diagnosis: ICD-10-code
Term Description
The condition that is the chief reason for providing care.
Source: Regenstrief LOINC
Observation ID in Form
M1021_A2_ICD
Form Coding Instructions
Column 1: Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided. Column 2: Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the underlying condition can often be entered in Column 2, as long as it is an active on-going condition impacting home health care
Source: Centers for Medicare & Medicaid ServicesFully-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
Normative Answer List LL3174-1
- Externally Defined
- Yes
- Code System
- ICD
- Code System OID
- 1.3.6.1.4.1.12009.10.1.2055
- Link to External List
- http://www.cdc.gov/nchs/icd/icd10cm.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: |
| it-IT | Italian (Italy) | Diagnosi primaria codice ICD: Synonyms: Clinico paziente Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 主要诊断 ICD 代码: Synonyms: ICD 分类型应答; |
85920-7 Primary Diagnosis Symptom Control Rating
Term Description
Assessment of the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider, the degree to which each condition limits daily activities, and if symptoms are controlled by current treatments.
Source: Regenstrief LOINC
Observation ID in Form
M1021_A2_Severity
Form Coding Instructions
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis code is a V, W, X, Y or Z-code. Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Symptom control rating
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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 LL4489-2
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Asymptomatic, no treatment needed at this time | 0 | LA27597-6 | |
| Symptoms well controlled with current therapy | 1 | LA27598-4 | |
| Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring | 2 | LA27599-2 | |
| Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring | 3 | LA27600-8 | |
| Symptoms poorly controlled; history of re-hospitalizations | 4 | LA27601-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |
85914-0 Optional Diagnosis: ICD-10-CM
Term Description
An underlying condition for an on-going diagnosis that has already resolved. This does not include underlying conditions for an on-going diagnosis that is also on-going; that condition can be reported as a secondary or co-morbid diagnosis.
Source: Regenstrief LOINC
Observation ID in Form
M1025_A3
Form Coding Instructions
Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment. Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when: a Z-code is reported in Column 2 AND the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated following a hysterectomy
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Underlying resolved condition ICD code
- Property
- Prid
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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 LL3174-1
- Externally Defined
- Yes
- Code System
- ICD
- Code System OID
- 1.3.6.1.4.1.12009.10.1.2055
- Link to External List
- http://www.cdc.gov/nchs/icd/icd10cm.htm
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |
86254-0 Optional Diagnosis: ICD-10-CM - multiple coding
Term Description
Additional codes for an underlying condition for an on-going diagnosis that has already resolved. For example, a manifestation code.
Source: Regenstrief LOINC
Observation ID in Form
M1025_B4 - M1025_F4
Form Coding Instructions
Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10- CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10- CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Underlying resolved condition.multiple coding ICD code
- Property
- Prid
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |
85913-2 Other Diagnoses
Term Description
Other/secondary/additional diagnoses that impact a patient's health
Source: Regenstrief LOINC
Observation ID in Form
M1023
Form Coding Instructions
Column 1: Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided). Column 2: ICD-10-CM and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses. Column 3: May be completed if a Z-code is assigned to Column 2 and the underlying diagnosis is resolved. Column 4: Complete only if the Optional Diagnosis is a multiple coding situation (for example: a manifestation code)
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Other diagnoses
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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
| LOINC | Long Common Name |
|---|---|
| 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] |
81885-6 Other Diagnoses: ICD-10-CM
Observation ID in Form
M1023_B2_ICD-M1023_F2_ICD
Fully-Specified Name
- Component
- Diagnosis.secondary
- Property
- Imp
- Time
- Pt
- System
- ^Patient
- Scale
- Nom
- Method
Additional Names
- Short Name
- Dx.secondary
Basic Attributes
- Class
- CLIN
- Type
- Clinical
- First Released
- Version 2.56
- Last Updated
- Version 2.73
- Order vs. Observation
- Observation
- Common Test Rank Get Info
- 11495
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 76464-7 | American Physical Therapy Association registry panel |
| 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) | Diagnóstico secundario: |
| it-IT | Italian (Italy) | Diagnosi.secondaria: Synonyms: Clinico Diagnosi secondaria Impressione/interpretazione di studio paziente Punto nel tempo (episodio) |
| zh-CN | Chinese (China) | 诊断.次要: Synonyms: 分类型应答; |
85920-7 Other Diagnoses Symptom Control Rating
Term Description
Assessment of the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider, the degree to which each condition limits daily activities, and if symptoms are controlled by current treatments.
Source: Regenstrief LOINC
Observation ID in Form
M1023_B2_Severity - M1023_F2_Severity
Form Coding Instructions
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis code is a V, W, X, Y or Z-code. Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Symptom control rating
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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 LL4489-2
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Asymptomatic, no treatment needed at this time | 0 | LA27597-6 | |
| Symptoms well controlled with current therapy | 1 | LA27598-4 | |
| Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring | 2 | LA27599-2 | |
| Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring | 3 | LA27600-8 | |
| Symptoms poorly controlled; history of re-hospitalizations | 4 | LA27601-6 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |
85914-0 Optional Diagnosis: ICD-10-CM
Term Description
An underlying condition for an on-going diagnosis that has already resolved. This does not include underlying conditions for an on-going diagnosis that is also on-going; that condition can be reported as a secondary or co-morbid diagnosis.
Source: Regenstrief LOINC
Observation ID in Form
M1025_B3-M1025_F3
Form Coding Instructions
Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment. Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when: a Z-code is reported in Column 2 AND the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated following a hysterectomy
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Underlying resolved condition ICD code
- Property
- Prid
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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 LL3174-1
- Externally Defined
- Yes
- Code System
- ICD
- Code System OID
- 1.3.6.1.4.1.12009.10.1.2055
- Link to External List
- http://www.cdc.gov/nchs/icd/icd10cm.htm
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |
86254-0 Optional Diagnosis: ICD-10-CM - multiple coding
Term Description
Additional codes for an underlying condition for an on-going diagnosis that has already resolved. For example, a manifestation code.
Source: Regenstrief LOINC
Observation ID in Form
M1025_B4 - M1025_F4
Form Coding Instructions
Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10- CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10- CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Underlying resolved condition.multiple coding ICD code
- Property
- Prid
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- 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
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |