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
CONTROL_ITEMS_FILLER Filler Filler 200 213-412 Control items filler
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
ITEM_FILLER_001 Filler Filler 1 699-699 Item filler: replaces old O5000
ITEM_FILLER_002 Filler Filler 1 700-700 Item filler: replaces old O5010A1
ITEM_FILLER_003 Filler Filler 1 701-701 Item filler: replaces old O5010A2
ITEM_FILLER_004 Filler Filler 1 702-702 Item filler: replaces old O5010A3
ITEM_FILLER_005 Filler Filler 1 703-703 Item filler: replaces old O5010B1
ITEM_FILLER_006 Filler Filler 1 704-704 Item filler: replaces old O5010B2
ITEM_FILLER_007 Filler Filler 1 705-705 Item filler: replaces old O5010B3
ITEM_FILLER_008 Filler Filler 1 706-706 Item filler: replaces old O5010C1
ITEM_FILLER_009 Filler Filler 1 707-707 Item filler: replaces old O5010C2
ITEM_FILLER_010 Filler Filler 1 708-708 Item filler: replaces old O5010C3
ITEM_FILLER_011 Filler Filler 1 709-709 Item filler: replaces old O5010D1
ITEM_FILLER_012 Filler Filler 1 710-710 Item filler: replaces old O5010D2
ITEM_FILLER_013 Filler Filler 1 711-711 Item filler: replaces old O5010D3
ITEM_FILLER_014 Filler Filler 1 712-712 Item filler: replaces old O5010E1
ITEM_FILLER_015 Filler Filler 1 713-713 Item filler: replaces old O5010E2
ITEM_FILLER_016 Filler Filler 1 714-714 Item filler: replaces old O5010E3
ITEM_FILLER_017 Filler Filler 1 715-715 Item filler: replaces old O5010F1
ITEM_FILLER_018 Filler Filler 1 716-716 Item filler: replaces old O5010F2
ITEM_FILLER_019 Filler Filler 1 717-717 Item filler: replaces old O5010F3
ITEM_FILLER_020 Filler Filler 1 718-718 Item filler: replaces old O5020
ITEM_FILLER_021 Filler Filler 1 719-719 Item filler: replaces old O5030A1
ITEM_FILLER_022 Filler Filler 1 720-720 Item filler: replaces old O5030A2
ITEM_FILLER_023 Filler Filler 1 721-721 Item filler: replaces old O5030A3
ITEM_FILLER_024 Filler Filler 1 722-722 Item filler: replaces old O5030A4
ITEM_FILLER_025 Filler Filler 1 723-723 Item filler: replaces old O5030B1
ITEM_FILLER_026 Filler Filler 1 724-724 Item filler: replaces old O5030B2
ITEM_FILLER_027 Filler Filler 1 725-725 Item filler: replaces old O5030B3
ITEM_FILLER_028 Filler Filler 1 726-726 Item filler: replaces old O5030B4
ITEM_FILLER_029 Filler Filler 1 727-727 Item filler: replaces old O5030C1
ITEM_FILLER_030 Filler Filler 1 728-728 Item filler: replaces old O5030C2
ITEM_FILLER_031 Filler Filler 1 729-729 Item filler: replaces old O5030C3
ITEM_FILLER_032 Filler Filler 1 730-730 Item filler: replaces old O5030C4
ITEM_FILLER_033 Filler Filler 1 731-731 Item filler: replaces old O5030D1
ITEM_FILLER_034 Filler Filler 1 732-732 Item filler: replaces old O5030D2
ITEM_FILLER_035 Filler Filler 1 733-733 Item filler: replaces old O5030D3
ITEM_FILLER_036 Filler Filler 1 734-734 Item filler: replaces old O5030D4
ITEM_FILLER_037 Filler Filler 1 735-735 Item filler: replaces old O5030E1
ITEM_FILLER_038 Filler Filler 1 736-736 Item filler: replaces old O5030E2
ITEM_FILLER_039 Filler Filler 1 737-737 Item filler: replaces old O5030E3
ITEM_FILLER_040 Filler Filler 1 738-738 Item filler: replaces old O5030E4
ITEM_FILLER_041 Filler Filler 1 739-739 Item filler: replaces old O5030F1
ITEM_FILLER_042 Filler Filler 1 740-740 Item filler: replaces old O5030F2
ITEM_FILLER_043 Filler Filler 1 741-741 Item filler: replaces old O5030F3
ITEM_FILLER_044 Filler Filler 1 742-742 Item filler: replaces old O5030F4
Z0500B Asmt Date 8 668-675 Date of signature verifying record completion
ASMT_ITEMS_FILLER Filler Filler 933 743-1675 Assessment 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)
C_HICN_MBI_IND Calc Text 1 1813-1813 Calculated HICN MBI Indicator
C_SSNRI_TRNSLTN_HICN_TXT Calc Text 12 1814-1825 SSNRI Translation HICN Text
C_SSNRI_TRNSLTN_MBI_TXT Calc Text 12 1826-1837 SSNRI Translation MBI Text
CALCULATED_ITEMS_FILLER Filler Filler 463 1838-2300 Calculated items filler
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: 08/06/2020 09:24:06 AM