99161-2 Administrative Information

Observation ID in Form

A

Fully-Specified Name

Component

OASIS E - Administrative information - ROC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.72

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

• 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

46498-2 Resumption of Care Date

Term Description

Date care resumed (e.g. the date of the first visit following an inpatient stay by a patient currently receiving service from a home health agency).
Source: Regenstrief LOINC

Observation ID in Form

M0032

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Resumption of care date

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

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

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

57201-6 Date of Physician-ordered Start of Care (Resumption of Care)

Observation ID in Form

M0102

Skip Logic

Skip to M0110, Episode Timing, if date entered

Form Coding Instructions

If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified.

Fully-Specified Name

Component

Date of Physician-ordered Start of Care (Resumption of Care)

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

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 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
• Started
• Survey

Example Units

Related Codes

57202-4 Date of Referral

Observation ID in Form

M0104

Form Coding Instructions

Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA.

Fully-Specified Name

Component

Date of Referral

Property

Date

Time

Pt

System

^Patient

Scale

Qn

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

Updated METHOD from CMS assessment to method-less since this is a general concept and not specific to CMS assessments.

Order vs. Observation

Observation

Member of these Panels

Related Names

• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey

Example Units

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.

101351-5 Transportation. Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Observation ID in Form

A1250

Fully-Specified Name

Component

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.74

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 LL6295-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Job
• Nominal
• Occupation
• Report period
• 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.

57204-0 From which of the following Inpatient Facilities was the patient discharged within the past 14 days?

Observation ID in Form

M1000

Skip Logic

If NA, Skip to B1300, Health Literacy

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Inpatient discharge facility within the past 14D

Property

Type

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

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; Changed TIME from Pt to 14D to reflect the term definition "within the past 14 days"; Added timing to the Component to follow LOINC convention

Order vs. Observation

Observation

Normative Answer List LL775-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Last
• Nominal
• Survey
• Typ

Related Codes

86470-2 Inpatient Discharge Date (most recent)

Observation ID in Form

M1005

Fully-Specified Name

Component

Most recent inpatient discharge date in the last 14D

Property

Date

Time

14D

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.63

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Past
• QNT
• Quan
• Quant
• Quantitative
• Survey

Example Units

Related Codes

93166-7 Hearing, Speech, and Vision

Observation ID in Form

B

Fully-Specified Name

Component

IRF-PAI v4.0, OASIS E - Hearing, speech, and vision - ROC, DC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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

Related Codes

103709-2 Health Literacy. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?

Observation ID in Form

B1300

Fully-Specified Name

Component

How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy

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

Survey Question

Text

How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?

Source

Single Item Literacy Screener

Normative Answer List LL4911-5

Member of these Panels

Related Names

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

Related Codes

Copyright

Organization

Dr. Nancy Morris

Copyright

© 2006 Morris et al.

Terms of Use

Used with permission

99140-6 Cognitive Patterns

Observation ID in Form

C

Fully-Specified Name

Component

OASIS E - Cognitive Patterns - SOC, ROC, DC

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.72

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

Related Codes

46589-8 Cognitive Functioning

Term Description

Identifies the patient's current level of cognitive functioning, including alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
Source: Regenstrief LOINC

Observation ID in Form

M1700

Fully-Specified Name

Component

Cognitive functioning

Property

Find

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

Order vs. Observation

Observation

Normative Answer List LL281-7

Member of these Panels

Related Names

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

Related Codes

58104-1 When Confused

Observation ID in Form

M1710

Form Coding Instructions

Reported or observed within the last 14 days.

Fully-Specified Name

Component

When confused within the last 14D

Property

Find

Time

14D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.61

Change Reason

Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee;Removed "reported or observed" from the COMPONENT because an oberservation of this nature must either be reported or observed, and therefore stating so is redundant;Changed "days" to "D" to match LOINC conventions for abbreviating time

Order vs. Observation

Observation

Normative Answer List LL282-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• When confused reported or observed within the last 14D

Related Codes

86495-9 When Anxious

Observation ID in Form

M1720

Form Coding Instructions

Reported or observed within the last 14 days.

Fully-Specified Name

Component

When anxious within the last 14D

Property

Find

Time

14D

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.63

Order vs. Observation

Observation

Normative Answer List LL283-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

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 (from CAM©)

Form Coding Instructions

Attempt to conduct interview with all patients.

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 2.77

Order vs. Observation

Both

Panel Type

Panel

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 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 (Orientation to year, month, and day)

Observation ID in Form

C0300

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 2.77

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 2.77

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 2.72

Order vs. Observation

Order

Panel Type

Panel

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

Additional Copyright

Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission.

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/

93170-9 Mood

Observation ID in Form

D

Fully-Specified Name

Component

IRF-PAI v4.0, LCDS v5.00, OASIS E - Mood

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.67

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: added OASIS E;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

54635-8 Patient Mood Interview (PHQ-2 to 9)

Reference Information

Observation ID in Form

D0150

Skip Logic

If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.

Form Coding Instructions

Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?" If symptom is present, enter 1 (yes) in column 1, Symptom Presence. If yes in column 1, then ask the patient: "About how often have you been bothered by this?" Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.

Fully-Specified Name

Component

Resident mood interview (PHQ-9)

Property

-

Time

2W

System

^Patient

Scale

-

Method

Reported.PHQ-9.CMS

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.72

Change Reason

Release 2.70: TIME_ASPCT: Updated to reflect Timing of all panel elements.; Previous Releases: Updated METHOD to Reported.PHQ-9.CMS to use term across CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• 14 days
• 2 weeks
• Mental health
• MentalHealth
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Patient Health Questionnaire
• PHQ9
• Pnl
• Psych
• Psychiatry
• Survey

Related Codes

Copyright

Organization

Pfizer, Inc

Copyright

Copyright © Pfizer Inc. All rights reserved.

Terms of Use

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

URL

https://www.phqscreeners.com/

86843-0 Symptom Presence

Observation ID in Form

D0150_1

Form Coding Instructions

If 0, enter 0 for Symptom Presence. If 1, enter 0-3 for Symptom Presence. If 9, leave Symptom Presence blank.

Fully-Specified Name

Component

Resident mood interview (PHQ-9) - symptom presence in the last 2W

Property

-

Time

2W

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.67

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels