54605-1 Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

Observation ID in Form

C0100

Skip Logic

If 0, skip to C1310, Signs and Symptoms of Delirium. If 1, continue to C0200. Repetition of Three Words.

Form Coding Instructions

Attempt to conduct interview with all patients

Form Coding Instructions

(3-day assessment period)

Fully-Specified Name

Component

Brief interview for mental status should 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 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Removed Survey Question Text and Source since that information is included in other parts of the term;

Order vs. Observation

Observation

Normative Answer List LL691-7

Member of these Panels

Related Names

• BIMS
• BIMS should be conducted
• 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.

103694-6 Brief Interview for Mental Status

Fully-Specified Name

Component

Brief interview for mental status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.78

Change Reason

Release 2.78: ORDER_OBS: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”; PanelType: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• BIMS
• Centers for Medicare and Medicaid Assessment
• Report period
• Survey

103696-1 Repetition of Three Words

Observation ID in Form

C0200

Form Coding Instructions

After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times

Form Context

Number of words repeated after first attempt

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

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL687-5

Member of these Panels

Related Names

• 3
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• Number
• 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.

103702-7 Temporal Orientation

Observation ID in Form

C0300

Form Context

(orientation to year, month, and day)

Fully-Specified Name

Component

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

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.78

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Report period
• Survey
• Temporal orientation (orientation to year, month, and day) - MDSv3

Related Codes

103697-9 Able to report correct year

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

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL643-8

Member of these Panels

Related Names

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

Related Codes

103698-7 Able to report correct month

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

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL644-6

Member of these Panels

Related Names

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

Related Codes

103703-5 Able to report correct day of the week

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

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL645-3

Member of these Panels

Related Names

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

Related Codes

103695-3 Recall

Observation ID in Form

C0400

Form Coding Instructions

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

Fully-Specified Name

Component

Recall

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.78

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

103699-5 Able to recall "sock"

Observation ID in Form

C0400A

Fully-Specified Name

Component

Recall - sock

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL646-1

Member of these Panels

Related Names

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

Related Codes

103700-1 Able to recall "blue"

Observation ID in Form

C0400B

Fully-Specified Name

Component

Recall - blue

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL647-9

Member of these Panels

Related Names

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

Related Codes

103701-9 Able to recall "bed"

Observation ID in Form

C0400C

Fully-Specified Name

Component

Recall - bed

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Normative Answer List LL648-7

Member of these Panels

Related Names

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

Related Codes

103704-3 BIMS Summary Score

Observation ID in Form

C0500

Form Coding Instructions

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

Fully-Specified Name

Component

Brief interview for mental status - summary score

Property

Score

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.77

Last Updated

Version 2.77

Order vs. Observation

Observation

Member of these Panels

Related Names

• BIMS
• BIMS summary score
• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Scale
• Survey

Example Units

Related Codes

95816-5 Signs and Symptoms of Delirium (from CAM)

Observation ID in Form

C1310

Form Coding Instructions

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record

Fully-Specified Name

Component

Signs and Symptoms of Delirium (from CAM)

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.78

Change Reason

Release 2.78: ORDER_OBS: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”; PanelType: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”;

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
• Sx

Related Codes

95813-2 Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline?

Observation ID in Form

C1310A

Fully-Specified Name

Component

Is there evidence of an acute change in mental status from the patient's baseline

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

Order vs. Observation

Observation

Survey Question

Text

[Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline?

Source

CAM.1

Normative Answer List LL251-0

Member of these Panels

Related Names

• Exchange
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Replace
• Report period
• S prime
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

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.

95812-4 Inattention - Did the patient have difficulty focusing attention, for example being easily distractible or having difficulty keeping track of what was being said?

Observation ID in Form

C1310B

Fully-Specified Name

Component

Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

Order vs. Observation

Observation

Survey Question

Text

[Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

Source

CAM.2A

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

95814-0 Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

Observation ID in Form

C1310C

Fully-Specified Name

Component

Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

Order vs. Observation

Observation

Survey Question

Text

[Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Source

CAM.3

Normative Answer List LL652-9

Member of these Panels

Related Names

• Arterial Stenosis
• Dynamic
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• S prime
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

95815-7 Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria?

Term Description

This term is the CMS Assessment adaption of question 4 on the Confusion Assessment Method (CAM): "[Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)"
Source: Regenstrief LOINC

Observation ID in Form

C1310D

Fully-Specified Name

Component

Altered level of consciousness

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.69

Last Updated

Version 2.69

Order vs. Observation

Observation

Survey Question

Text

Altered level of consciousness - Did the patient have altered level of consciousness as indicated by any of the following criteria? Vigilant - startled easily to any sound or touch, Lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch, Stuporous - very difficult to arouse and keep aroused for the interview, Comatose - could not be aroused

Source

CMS

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Levels
• Levl
• LV
• LVL
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/