Form CMS-10390 Hospice Item Set - Discharge

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 09381153. The time required to complete this information collection is estimated to
average 10 minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Hospice Item Set – Discharge
Section A

Administrative Information

A0050. Type of Record
Enter Code

1. Add new record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers. Enter code in boxes provided.
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

A0220. Admission Date

Month

A0250. Reason for Record
Enter Code

Day

Year

Day

Year

01. Admission
09. Discharge

A0270. Discharge Date
Month

A0500. Legal Name of Patient
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

Hospice Item Set – Discharge
Draft V1.00.0 Effective July 1, 2014

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Section A

Administrative Information

A0600. Social Security and Medicare Numbers
A. Social Security Number:

-

-

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid Recipient
A0800. Gender
Enter Code

1. Male
2. Female

A0900. Birth Date

Month

A2115. Reason for Discharge
Enter Code

Day

Year

01. Expired
02. Revoked
03. No longer terminally ill
04. Moved out of hospice service area
05. Transferred to another hospice
06. Discharged for cause

Hospice Item Set – Discharge
Draft V1.00.0 Effective July 1, 2014

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Section Z

Record Administration

Z0400. Signature(s) of Person(s) Completing the Record
I certify that the accompanying information accurately reflects patient assessment information for
this patient and that I collected or coordinated collection of this information on the dates specified. To the
best of my knowledge, this information was collected in accordance with applicable Medicare and
Medicaid requirements. I understand that reporting this information is used as a basis for payment from
federal funds. I further understand that failure to report such information may lead to a 2 percentage point
reduction in the Fiscal Year payment determination. I also certify that I am authorized to submit this
information by this provider on its behalf.
Signature

Title

Sections

Date Section
Completed

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Z0500. Signature of Person Verifying Record Completion
A. Signature:

_____________________________________________________

Hospice Item Set – Discharge
Draft V1.00.0 Effective July 1, 2014

B. Date:

Month

Day

Year

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