88491-6
PATIENT HISTORY AND DIAGNOSES
Active
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
Source: Centers for Medicare & Medicaid ServicesFully-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
| LOINC | Long Common Name |
|---|---|
| 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] |
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
Source: Centers for Medicare & Medicaid ServicesFully-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
| LOINC | Long Common Name |
|---|---|
| 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] |
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
| 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
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
| 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] |
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
Source: Centers for Medicare & Medicaid ServicesFully-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
| LOINC | Long Common Name |
|---|---|
| 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] |
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
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
| 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] |
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
Source: Consensus measures for Phenotypes and ExposuresFully-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
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Intravenous or infusion therapy (excludes TPN) | 1 | LA6244-3 | |
| Parenteral nutrition (TPN or lipids) | 2 | LA6321-9 | |
| Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal) | 3 | LA6194-0 | |
| None of the above | 4 | LA9-3 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 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] |