Hospice Item Summary

Item

Group

Type

Length

Fixed Start-End

Description

ITM_SET_SYS_CD Control Code 10 1-10 Item set system code
ITM_SBST_CD Control Code 3 11-13 Item subset code
ITM_SET_VRSN_CD Control Code 10 14-23 Item set version code
SPEC_VRSN_CD Control Code 10 24-33 Specifications version code
CRCTN_NUM Control Number 2 34-35 Correction number
STATE_CD Control Code 2 36-37 Provider"s state postal code
FAC_ID Control Text 16 38-53 Assigned provider submission ID
SFTWR_VNDR_ID Control Text 9 54-62 Software vendor federal employer tax ID
SFTWR_VNDR_NAME Control Text 30 63-92 Software vendor company name
SFTWR_VNDR_EMAIL_ADR Control Text 50 93-142 Software vendor email address
SFTWR_PROD_NAME Control Text 50 143-192 Software product name
SFTWR_PROD_VRSN_CD Control Text 20 193-212 Software product version code
A0050 Asmt Code 1 413-413 Type of record
A0100A Asmt Text 10 414-423 Facility National Provider Identifier (NPI)
A0100B Asmt Text 12 424-435 Facility CMS Certification Number (CCN)
A0205 Asmt Code 2 436-437 Site of service at admission
A0220 Asmt Date 8 438-445 Admission date
A0245 Asmt Date 8 446-453 Date initial nursing assessment initiated
A0250 Asmt Code 2 454-455 Reason for record
A0270 Asmt Date 8 456-463 Discharge date
A0500A Asmt Text 12 464-475 Patient first name
A0500B Asmt Text 1 476-476 Patient middle initial
A0500C Asmt Text 18 477-494 Patient last name
A0500D Asmt Text 3 495-497 Patient name suffix
A0550 Asmt Text 11 676-686 Patient zip code
A0600A Asmt Text 9 498-506 Social Security Number
A0600B Asmt Text 12 507-518 Patient Medicare/railroad insurance number
A0700 Asmt Text 14 519-532 Patient Medicaid number
A0800 Asmt Code 1 533-533 Gender
A0900 Asmt Date 8 534-541 Birthdate
A1000A Asmt Checklist 1 542-542 Ethnicity: American Indian or Alaska Native
A1000B Asmt Checklist 1 543-543 Ethnicity: Asian
A1000C Asmt Checklist 1 544-544 Ethnicity: Black or African American
A1000D Asmt Checklist 1 545-545 Ethnicity: Hispanic or Latino
A1000E Asmt Checklist 1 546-546 Ethnicity: Native Hawaiian/Pacific Islander
A1000F Asmt Checklist 1 547-547 Ethnicity: White
A1400A Asmt Checklist 1 687-687 Payor: Medicare (FFS)
A1400B Asmt Checklist 1 688-688 Payor: Medicare (managed care/Part C/Mcr Advant.)
A1400C Asmt Checklist 1 689-689 Payor: Medicaid (FFS)
A1400D Asmt Checklist 1 690-690 Payor: Medicaid (managed care)
A1400G Asmt Checklist 1 691-691 Payor: Other Government
A1400H Asmt Checklist 1 692-692 Payor: Private insurance/Medigap
A1400I Asmt Checklist 1 693-693 Payor: Private managed care
A1400J Asmt Checklist 1 694-694 Payor: Self-pay
A1400K Asmt Checklist 1 695-695 Payor: No payor source
A1400X Asmt Checklist 1 696-696 Payor: Unknown
A1400Y Asmt Checklist 1 697-697 Payor: Other
A1802 Asmt Code 2 548-549 Admitted from
A2115 Asmt Code 2 550-551 Reason for discharge
F2000A Asmt Code 1 552-552 Was patient asked about CPR
F2000B Asmt Date 8 553-560 Date asked about CPR
F2100A Asmt Code 1 561-561 Was patient asked about treatments other than CPR
F2100B Asmt Date 8 562-569 Date asked about treatment other than CPR
F2200A Asmt Code 1 570-570 Was patient asked about hospitalization
F2200B Asmt Date 8 571-578 Date asked about hospitalization
F3000A Asmt Code 1 579-579 Was patient asked spiritual/existential concerns
F3000B Asmt Date 8 580-587 Date asked about spiritual/existential concerns
I0010 Asmt Code 2 588-589 Principal diagnosis
J0900A Asmt Code 1 590-590 Was patient screened for pain
J0900B Asmt Date 8 591-598 Date of first screening for pain
J0900C Asmt Code 1 599-599 Patient"s pain severity was
J0900D Asmt Code 1 600-600 Type of standardized pain tool used
J0905 Asmt Code 1 698-698 Is pain an active problem for the patient?
J0910A Asmt Code 1 601-601 Was comprehensive pain assessment done
J0910B Asmt Date 8 602-609 Date of comprehensive pain assessment
J0910C1 Asmt Code 1 610-610 Pain asmt included: location
J0910C2 Asmt Code 1 611-611 Pain asmt included: severity
J0910C3 Asmt Code 1 612-612 Pain asmt included: character
J0910C4 Asmt Code 1 613-613 Pain asmt included: duration
J0910C5 Asmt Code 1 614-614 Pain asmt included: frequency
J0910C6 Asmt Code 1 615-615 Pain asmt included: what relieves/worsens
J0910C7 Asmt Code 1 616-616 Pain asmt included: effect function/quality life
J0910C9 Asmt Code 1 617-617 Pain asmt included: none of the above
J2030A Asmt Code 1 618-618 Was patient screened for shortness of breath
J2030B Asmt Date 8 619-626 Date of first screening for shortness of breath
J2030C Asmt Code 1 627-627 Did screening indicate pt had shortness of breath
J2040A Asmt Code 1 628-628 Was treatment for shortness of breath initiated
J2040B Asmt Date 8 629-636 Date treatment for shortness of breath initiated
J2040C1 Asmt Checklist 1 637-637 Type(s) treat for shortness of breath: opioids
J2040C2 Asmt Checklist 1 638-638 Type(s) treat for shortness of breath: other med
J2040C3 Asmt Checklist 1 639-639 Type(s) treat for shortness of breath: oxygen
J2040C4 Asmt Checklist 1 640-640 Type(s) treat for shortness of breath: non-med
N0500A Asmt Code 1 641-641 Was scheduled opioid initiated or continued
N0500B Asmt Date 8 642-649 Date scheduled opioid initiated or continued
N0510A Asmt Code 1 650-650 Was PRN opioid initiated or continued
N0510B Asmt Date 8 651-658 Date PRN opioid initiated or continued
N0520A Asmt Code 1 659-659 Was bowel regimen initiated or continued
N0520B Asmt Date 8 660-667 Date bowel regimen initiated or continued
O5000 Asmt Code 1 699-699 Level of care in final 3 days
O5010A1 Asmt Number 1 700-700 RN - Num visits - day of death
O5010A2 Asmt Number 1 701-701 RN - Num visits - one day prior to death
O5010A3 Asmt Number 1 702-702 RN - Num visits - two days prior to death
O5010B1 Asmt Number 1 703-703 Phys - Num visits - day of death
O5010B2 Asmt Number 1 704-704 Phys - Num visits - one day prior to death
O5010B3 Asmt Number 1 705-705 Phys - Num visits - two days prior to death
O5010C1 Asmt Number 1 706-706 Soc Wrk - Num visits - day of death
O5010C2 Asmt Number 1 707-707 Soc Wrk - Num visits - one day prior to death
O5010C3 Asmt Number 1 708-708 Soc Wrk - Num visits - two days prior to death
O5010D1 Asmt Number 1 709-709 Chaplain - Num visits - day of death
O5010D2 Asmt Number 1 710-710 Chaplain - Num visits - one day prior to death
O5010D3 Asmt Number 1 711-711 Chaplain - Num visits - two days prior to death
O5010E1 Asmt Number 1 712-712 Lic Nurse - Num visits - day of death
O5010E2 Asmt Number 1 713-713 Lic Nurse - Num visits - one day prior to death
O5010E3 Asmt Number 1 714-714 Lic Nurse - Num visits - two days prior to death
O5010F1 Asmt Number 1 715-715 Aide - Num visits - day of death
O5010F2 Asmt Number 1 716-716 Aide - Num visits - one day prior to death
O5010F3 Asmt Number 1 717-717 Aide - Num visits - two days prior to death
O5020 Asmt Code 1 718-718 Level of care in final 7 days
O5030A1 Asmt Number 1 719-719 RN - Num visits - three days prior to death
O5030A2 Asmt Number 1 720-720 RN - Num visits - four days prior to death
O5030A3 Asmt Number 1 721-721 RN - Num visits - five days prior to death
O5030A4 Asmt Number 1 722-722 RN - Num visits - six days prior to death
O5030B1 Asmt Number 1 723-723 Phys - Num visits - three days prior to death
O5030B2 Asmt Number 1 724-724 Phys - Num visits - four days prior to death
O5030B3 Asmt Number 1 725-725 Phys - Num visits - five days prior to death
O5030B4 Asmt Number 1 726-726 Phys - Num visits - six days prior to death
O5030C1 Asmt Number 1 727-727 Soc Wrk - Num visits - three days prior to death
O5030C2 Asmt Number 1 728-728 Soc Wrk - Num visits - four days prior to death
O5030C3 Asmt Number 1 729-729 Soc Wrk - Num visits - five days prior to death
O5030C4 Asmt Number 1 730-730 Soc Wrk - Num visits - six days prior to death
O5030D1 Asmt Number 1 731-731 Chaplain - Num visits - three days prior to death
O5030D2 Asmt Number 1 732-732 Chaplain - Num visits - four days prior to death
O5030D3 Asmt Number 1 733-733 Chaplain - Num visits - five days prior to death
O5030D4 Asmt Number 1 734-734 Chaplain - Num visits - six days prior to death
O5030E1 Asmt Number 1 735-735 Lic Nurse - Num visits - three days prior to death
O5030E2 Asmt Number 1 736-736 Lic Nurse - Num visits - four days prior to death
O5030E3 Asmt Number 1 737-737 Lic Nurse - Num visits - five days prior to death
O5030E4 Asmt Number 1 738-738 Lic Nurse - Num visits - six days prior to death
O5030F1 Asmt Number 1 739-739 Aide - Num visits - three days prior to death
O5030F2 Asmt Number 1 740-740 Aide - Num visits - four days prior to death
O5030F3 Asmt Number 1 741-741 Aide - Num visits - five days prior to death
O5030F4 Asmt Number 1 742-742 Aide - Num visits - six days prior to death
Z0500B Asmt Date 8 668-675 Date of signature verifying record completion
ASMT_ITEMS_FILLER Filler Filler 933 743-1675 Assessment items filler
CONTROL_ITEMS_FILLER Filler Filler 200 213-412 Control items filler
CALCULATED_ITEMS_FILLER Filler Filler 488 1813-2300 Calculated items filler
ASSESSMENT_ID Calc Number 15 1676-1690 Assessment internal ID
ORIGINAL_ASSESSMENT_ID Calc Number 15 1691-1705 Original assessment ID
RESIDENT_INTERNAL_ID Calc Number 10 1706-1715 Resident internal ID
TARGET_DATE Calc Date 8 1716-1723 Target date
PROVIDER_INTERNAL_ID Calc Number 10 1724-1733 Provider internal ID
SUBMISSION_ID Calc Number 15 1734-1748 Submission ID
SUBMISSION_DATE Calc Date 8 1749-1756 Submission date
SUBMISSION_COMPLETE_DATE Calc Date 8 1757-1764 Submission processing completion date
SUBMITTING_USER_ID Calc Text 30 1765-1794 Submitter user ID
RESIDENT_MATCH_CRITERIA Calc Number 2 1795-1796 Resident matching criteria
RESIDENT_AGE Calc Number 3 1797-1799 Age of resident on the target date
BIRTHDATE_SUBMIT_CODE Calc Code 1 1800-1800 Birth date submit code
C_CCN_NUM Calc Text 12 1801-1812 Calculated Facility CMS Certification Number (CCN)
DATA_END_INDICATOR Calc Code 1 2301-2301 End of data terminator code
CR Calc Code 1 2302-2302 Carriage return (ASCII 013)
LF Calc Code 1 2303-2303 Line feed character (ASCII 010)

NOTICE: These materials are in the public domain and cannot be copyrighted.
Generated: 05/18/2016 08:32:30 AM