CMS-10151 Crosswalk from old to new collection form_2012_compliant 508

Crosswalk (Old and New Collection Form for OCN: 0938-0967)

Issue
#
1.

Page #
All

Section

Action to be
performed
Change header

Changes to the Application

Reason for the Change

Reflect current version number

Add language to title
of document
Change heading title

Add extended title of document to include “Generator
and Leads”
Change heading title from “Participant
Administration” to “Demographics”
Delete Participant ID, Medicare Provider # and
Participant NPI
All fields from section B are moved into the new
section A
Change field name from “gender” to “sex”
Delete “Auxiliary 1” and “Auxiliary 2”

To identify version of collection
form
To better identify the data being
collected in the instrument
Participant Administration
subheading has been replaced
Data is collected at a higher level
and not on each patient form
Original Section A was deleted

2.

All

3.

1

Across top of
pages
Across top of
page
A

4.

1

A

Delete fields

5.

1

B

Change fields

6.
7.

1
1

B
B

Change field
Delete fields

8.
9.

1
1

B
C

Change header
Change fields

10.

1

C

Change field

Change “demographics” to “Episode of care”
All fields from Section C are moved into the new
Section B
Change “Admission Date” to “Arrival Date”

11.
12.
13.
14.

1
1
1
1

C
C
C
C

Delete field
Delete field
Delete fields
Add field

Delete “date of implant”
Delete “reason for admission”
Deleted “auxiliary 3” and “auxiliary 4”
Add “Patient Zip Code”

15.

1

C

Add field

Add “HIC”

More accurate description of field
No longer needed with new
version of form
editorial
Shift in sections
Better characterizes the patient
medical record
No longer needed
No longer needed
No longer needed
Field added to improve research
abilities by better matching with
Medicare claims data
Field added to improve research
abilities by better matching with
Medicare claims data

Page 1 of 3

16.

1

D

Move fields

Move fields for CHF to the first field in this section

17.
18.
19.
20.

1
1
1
1

D
D
D
D

Change field
Add field
Add field
Change fields

21.

2

D

Add fields

22.
23.

2
2

E
E

Shift Section
Change field

24.
25.
26.
27.
28.
29.
30.
31.
32.

2
2
2
2
2
2
2
2
2

E
E
E
E
F
F
F
F
F

Add field
Add field
Add field
Add field
Change Header
Shift Section
Add field
Delete field
Delete field

33.
34.
35.

2
2
2

F
F
G

Add field
Add field
Change header

Change “CHF” to “Heart Failure”
Add “Prior Heart Transplant”
Add “On Heart Transplant Waiting List”
Change field titles “Previous MI”, “Previous CABG”,
“Previous PCI” to “Prior MI”, “Prior CABG”, “Prior
PCI”
Add “Height”, “Cerebrovascular Disease”, “Diabetes
Mellitus”, “Currently on Dialysis”, “Patient Life
Expectancy of >= 1 year”, “Weight”, “Chronic Lung
Disease”, “Sleep Apnea”, “Hypertension”
Section E will become the new Section D
Change “Ejection Fraction Assessed” to “LVEF
Assessed”
Add “12 Lead ECG w/Automated Measurements”
Add “Cardiac Rhythm(s)”
Add “Potassium”
Add “NT-proBNP”
Change “ICD Procedure” to Procedure Information
Section F becomes the new Section E
Add “Procedure Date/Time”
Delete “Implant Operator’s NPI”
Delete “Multiple ICDs implanted during this
admission”
Add “ATP or Shock Therapy Delivered”
Add “Device Explanted”
Change “Adverse Events” to “Lead Assessment”

Improve the logical flow of data
collection
Better description of data collected
To collect more complete data
To collect more complete data
Editorial

To collect more complete data

Editorial
To collect more complete data
To collect more complete data
To collect more complete data
To collect more complete data
Editorial
To collect more complete data
No longer needed
No longer needed
To collect more complete data
To collect more complete data
Adding new field to collect more
complete data

Page 2 of 3

36.

2

G

Add fields

37.

3

H

Change header

38.
39.

3
3

I
I

Change header
Change field

Add “Operator’s Name”, “NPI”, “TIN”, “Lead
Counter”, “Identification”, “Serial Number”, “Lead
Location”, “Existing Lead Implant Date”, Existing
Lead Function”, “Manufacturer Advisory/Recall”,
Existing Lead Status”, “Existing Lead Placement
Issues”, “Pacing Issues”, “Defibrillation Issues”,
“Lead integrity Issues”
Change “Discharge” to “Intra or Post Procedure
Events”
Change “Discharge Medications” to “Discharge”
Change “Vital Status” to “Discharge Status”

To collect more complete data

Shifting of fields
Better description of field
Editorial

Page 3 of 3