86245-8 CLINICAL RECORD ITEMS

Fully-Specified Name

Component

OASIS E - Administrative Information - FU

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; Release 2.72: COMPONENT: new section name in form;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

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 4, go to M0110. If 5, go to M0110.

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

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.

88491-6 PATIENT HISTORY AND DIAGNOSES

Fully-Specified Name

Component

OASIS D - Patient history and diagnoses - follow-up

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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
• Dextro
• Hx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Patient Hx
• Pnl
• Report period
• Survey

88488-2 Diagnoses and Symptom Control

Observation ID in Form

M1021, M1023

Form Coding Instructions

List each diagnosis for which the patient is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2 (diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses. Code each row according to the following directions for each column: 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. 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. Choose one value that represents the degree of symptom control appropriate for each diagnosis 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 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

Fully-Specified Name

Component

OASIS E - Diagnoses and symptom control

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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;

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
• Sx

Related Codes

88489-0 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

Fully-Specified Name

Component

OASIS E - Primary diagnosis

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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: NEW FORM;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

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

Fully-Specified Name

Component

Primary diagnosis ICD code

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Primary Dx ICD code

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.63

Last Updated

Version 2.73

Order vs. Observation

Both

Common Test Rank Get Info

17680

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

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

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

M1023_B2_Severity - M1023_F2_Severity

Fully-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

Member of these Panels

Related Names

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

Related Codes

88490-8 Other Diagnoses

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

Fully-Specified Name

Component

OASIS E - Other diagnoses

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

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

Language Variants Get Info

Related Names

• CLIN
• Dx
• Dx.secondary
• Impression
• Impression/interpretation of study
• Impressions
• Interp
• Interpretation
• Nominal
• Point in time
• Random

Related Codes

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

Fully-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

Member of these Panels

Related Names

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

Related Codes

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

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

88492-4 SENSORY STATUS

Fully-Specified Name

Component

OASIS D - Sensory status - start of care or resumption of care or follow-up

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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
• Dextro
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Started
• Survey

57215-6 Vision (with corrective lenses if the patient usually wears them)

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

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

88463-5 INTEGUMENTARY STATUS

Fully-Specified Name

Component

OASIS E - Skin Conditions - SOC, ROC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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; LONG_COMMON_NAME: Updated to include current version of OASIS that uses this panel;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

85918-1 Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?

Term Description

Excludes Stage 1 pressure inuries and all healed pressure ulcers/injuries.
Source: Regenstrief LOINC

Observation ID in Form

M1306

Skip Logic

If 0, go to M1322.

Form Coding Instructions

Excludes Stage 1 pressure injuries and all healed pressure ulcers/injuries

Fully-Specified Name

Component

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

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; Previous Releases: "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

Normative Answer List LL251-0

Member of these Panels

Related Names

• Arterial Stenosis
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• II
• Ordinal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

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.

88494-0 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

Observation ID in Form

M1311

Fully-Specified Name

Component

OASIS E - Current number of unhealed pressure injuries at each stage - SOC, ROC, FU

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• No
• Num
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Pressure ulcer
• Pressure Ulcers
• Report period
• Survey

Related Codes

55124-2 Number of Stage 2 pressure ulcers

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

M1311A1

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 Number of Stage 3 pressure ulcers

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

M1311B1

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 Number of Stage 4 pressure ulcers

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

M1311C1

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 Number of unstageable pressure ulcers/injuries due to non-removable dressing/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

M1311D1

Form Context

Unstageable: Non-removable dressing/device: Known but not stageable due to non-removable dressing/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 Number of unstageable pressure ulcers/injuries 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

M1311E1

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 Number of unstageable pressure injuries presenting as deep tissue injury

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

M1311F1

Form Context

Unstageable: Deep tissue injury

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

Related Names

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

Example Units

Related Codes

46536-9 Current Number of Stage 1 Pressure Injuries

Term Description

A stage 1 pressure injury is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
Source: Regenstrief LOINC

Observation ID in Form

M1322

Form Context

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues

Fully-Specified Name

Component

Number of pressure injuries - stage 1

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

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; Changed SCALE to Ord because this term has a normative answer list; "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

Normative Answer List LL5031-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• i
• No
• Num
• Number
• Ordinal
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey

Example Units

Related Codes

57231-3 Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable

Observation ID in Form

M1324

Form Coding Instructions

Excludes pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury

Fully-Specified Name

Component

Stage of most problematic pressure injury

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; Release 2.67: ANSWER_LIST_TYPE: Answer List Type changed to Example to accommodate Override Answer Lists; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; "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

Normative Answer List LL5032-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

57232-1 Does this patient have a Stasis Ulcer?

Observation ID in Form

M1330

Skip Logic

If 0, go to M1340. If 3, go to M1340.

Fully-Specified Name

Component

Stasis pressure injury

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; Release 2.73: COMPONENT: Update older "ulcer" terms to "pressure injury"; 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 LL4512-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

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.

57233-9 Current Number of Stasis Ulcer(s) that are Observable

Observation ID in Form

M1332

Fully-Specified Name

Component

Number of stasis ulcers

Property

Num

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 SCALE from Qn to Ord because this term has an answer list

Order vs. Observation

Observation

Normative Answer List LL795-6

Member of these Panels

Related Names

• # stasis ulcers
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Example Units

Related Codes

57234-7 Status of Most Problematic Stasis Ulcer that is Observable

Observation ID in Form

M1334

Fully-Specified Name

Component

Status of most problematic stasis pressure injury

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; Release 2.73: COMPONENT: Update older "ulcer" terms to "pressure injury"; 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 LL4513-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

57235-4 Does this patient have a Surgical Wound?

Observation ID in Form

M1340

Skip Logic

If 0, go to M1400. If 2, go to M1400.

Fully-Specified Name

Component

Surgical wound

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 LL849-1

Member of these Panels

Related Names

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

57236-2 Status of Most Problematic Surgical Wound that is Observable

Observation ID in Form

M1342

Fully-Specified Name

Component

Status of most problematic surgical wound

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