Form 31 Intestine Recipient Registration

Organ Procurement and Transplantation Network and Scientific Registry of Transplant Recipients Data System

31 Intestine Transplant Recipient Registration_Instructions

OPTN- Intestine Recipient Registration

OMB: 0915-0157

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0915-0157 can be found here:

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Intestine Transplant Recipient Registration (TRR) Record Field Descriptions

The Transplant Recipient Registration (TRR) records are generated and available immediately after a transplant event is reported through the recipient feedback process in Waitlist^SM. A TRR will also be generated in the case of a living donor transplant, where a recipient was added through the donor feedback process in Tiedi^®. The TRR record is completed by the transplant center performing the transplant. The registration and hospital discharge follow-up information is combined in this record.

Complete the TRR at hospital discharge or six weeks post transplant, whichever is first. If the recipient is still hospitalized at six weeks post transplant, provide the most recent information available regarding the recipient's progress.

The TRR record must be completed within 60 days from the record generation date. See OPTN Policy for additional information. Use the search feature to locate specific policy information on Data Submission Requirements.

To correct information that is already displayed on an electronic record, call the UNet^SM Help Desk at 1-800-978-4334.

Recipient Information

Name: Verify the last name, first name and middle initial of the transplant recipient is correct. If the information is incorrect, corrections may be made on the recipient's TCR record.

DOB: Verify the displayed date is the recipient's date of birth. If the information is incorrect, corrections may be made on the recipient's TCR record.

SSN: Verify the recipient's social security number is correct. If the information is incorrect, contact the Help Desk at 1-800-978-4334.

Gender: Verify the recipient's gender is correct. If the information is incorrect, corrections may be made on the recipient's TCR record.

HIC: Verify the 9 to 11 character Health Insurance Claim number for the recipient indicated on the recipient's most recently updated TCR record is correct. If the recipient does not have a HIC number, you may leave this field blank.

Tx Date: Verify the displayed transplant date is the date of the beginning of the first anastomosis. If the operation started in the evening and the first anastomosis began early the next morning, the transplant date is the date that the first anastomosis began. The transplant is considered complete when the cavity is closed and the final skin stitch/staple is applied. The transplant date is indicated immediately after a transplant event is reported through the recipient feedback process in Waitlist and in the case of a living donor transplant, where a recipient was added through the donor feedback process in Tiedi.

State of Permanent Residence: Select the name of the state of the recipient's permanent address at the time of transplant (location of full-time residence, not transplant center location). This field is required. (List of State codes – Appendix A)

Permanent Zip Code: Enter the recipient's permanent zip code at the time of transplant (location of full-time residence, not transplant center location). This field is required.

Provider Information

Recipient Center: The Recipient Center information reported in Waitlist displays. Verify that the center information is the hospital where the transplant operation was performed. The Provider Number is the 6-character Medicare identification number of the hospital. This is followed by the Center Code and Center Name.

Surgeon Name: Enter the name of the primary surgeon, who performed the transplant operation, and under whose name the transplant is billed. This field is required.

Surgeon NPI #: Enter the 10-character CMS (Center for Medicare and Medicaid Services) assigned National Provider Identifier of the transplant surgeon. Your hospital billing office may be able to obtain this number for you. This field is required.

Donor Information

UNOS Donor ID #: The UNOS Donor ID number, reported in the Recipient Feedback, will display. Each potential donor is assigned an identification number by OPTN/UNOS. This ID number corresponds to the date the donor information was entered into the OPTN/UNOS computer system.

Donor Type: The donor type, reported in the Recipient Feedback, will display. Verify the recipient's donor type is correct. If the information is incorrect, contact the Help Desk at 1-800-978-4334.

Deceased indicates the donor was not living at the time of donation.
Living indicates the donor was living at the time of donation.

Patient Status

Primary Diagnosis: Select the primary diagnosis for the disease requiring a transplant for this recipient. If the recipient has had a previous transplant for the same organ type, select Retransplant/Graft Failure as the primary diagnosis for that organ. If Other, Specify is selected, enter the primary diagnosis in the space provided. This field is required. (List of Intestine Diagnosis codes – Appendix R)

Secondary Diagnosis: Select the secondary diagnosis for the disease requiring a transplant for this recipient. If Other, Specify is selected, enter the secondary diagnosis in the space provided. (List of Intestine Diagnosis codes – Appendix R)

Date: Last Seen, Retransplanted or Death: Complete at discharge (if discharged prior to six weeks from transplant date) or at six weeks from transplant date, whichever occurs first. Enter the date the hospital reported the recipient as living, retransplanted (when the data was obtained prior to the recipient's discharge) or the date of the recipient's death, using the standard 8-digit numeric format of MM/DD/YYYY. This field is required.

Patient Status: Complete at discharge (if discharged prior to six weeks from transplant date) or at six weeks from transplant date, whichever occurs first. Select the appropriate status for this recipient. If Dead is selected, indicate the cause of death. This field is required.

Living
Dead
Retransplanted

Primary Cause of Death: If the Patient Status is Dead, select the patient's cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Primary Cause of Death codes – See Appendix W)

Contributory Cause of Death: If the Patient Status is Dead, select the patient's contributory cause of death. If an Other code is selected, enter the other cause of death in the space provided. (List of Contributory Cause of Death codes – See Appendix W)

Note: If the patient is being retransplanted, access the patient's last record for their previous transplant and select Retransplanted in the Patient Status field. This will stop the generation of TRF records associated with the previous transplant.

Transplant Hospitalization:

Date of Admission to Tx Center: Enter the date the recipient was admitted to the transplant center, using the 8-digit MM/DD/YYYY format. If the patient was admitted to the hospital before it was determined a transplant was needed, enter the date it was determined the patient needed a transplant. This field is required.

Date of Discharge From Tx Center: Enter the date the recipient was released to go home, using the 8-digit MM/DD/YYYY format. The recipient's hospital stay includes total time spent in different units of the hospital, including medical and rehab. This information is not required in the TRR record, but if entered here, it will automatically fill in the future TRF records. It is required in the TRF record.

Note: Leave this field blank if the recipient was removed from the waiting list with a code of 21, indicating the recipient died during the transplant procedure.

Clinical Information: Pretransplant

Medical Condition at time of transplant: Select the choice that best describes the recipient's condition and location just prior to the time of transplant. This field is required.

In Intensive Care Unit
Hospitalized Not in ICU
Not Hospitalized

Patient on Life Support: If the patient was on life support at the time of transplant, select Yes. If not, select No. If Yes is selected, check all that apply. If a type of life support used is not listed select Other Mechanism, Specify and specify the type in the space provided. This field is required.

Ventilator - Select only if the recipient is on continuous invasive ventilation
Artificial Liver
Other Mechanism, Specify

Functional Status: Select the choice that best describes the recipient's functional status just prior to the time of transplant. This field is required.

Note: The Karnofsky Index will display for adults aged 18 and older.

100% - Normal, no complaints, no evidence of disease
90% - Able to carry on normal activity: minor symptoms of disease
80% - Normal activity with effort: some symptoms of disease
70% - Cares for self: unable to carry on normal activity or active work
60% - Requires occasional assistance but is able to care for needs
50% - Requires considerable assistance and frequent medical care
40% - Disabled: requires special care and assistance
30% - Severely disabled: hospitalization is indicated, death not imminent
20% - very sick, hospitalization necessary: active treatment necessary
10% - Moribund, fatal processes progressing rapidly
Unknown

Note: The Lansky Score will display for pediatrics aged less than 18.

100% - Fully active, normal
90% - Minor restrictions in physically strenuous activity
80% - Active, but tires more quickly
70% - Both greater restriction of and less time spent in play activity
60% - Up and around, but minimal active play; keeps busy with quieter activities
50% - Can dress but lies around much of day; no active play; can take part in quiet play/activities
40% - Mostly in bed; participates in quiet activities
30% - In bed; needs assistance even for quiet play
20% - Often sleeping; play entirely limited to very passive activities
10% - No play; does not get out of bed
Not Applicable (patient < 1 year old)
Unknown

Note: This evaluation should be in comparison to the person's normal function, indicating how the patient's disease has affected their normal function.

Cognitive Development: (This field is required for recipients 18 years of age or younger.) Select the choice that best describes the recipient's cognitive development just prior to the time of transplant.

Definite Cognitive Delay/Impairment (verified by IQ score <70 or unambiguous behavioral observation)

Probable Cognitive Delay/Impairment (not verified or unambiguous but more likely than not, based on behavioral observation or other evidence)

Questionable Cognitive Delay/Impairment (not judged to be more likely than not, but with some indication of cognitive delay/impairment such as expressive/receptive language and/or learning difficulties)

No Cognitive Delay/Impairment (no obvious indicators of cognitive delay/impairment)

Not Assessed

Motor Development: (This field is required for recipients 18 years of age or younger.) Select the choice that best describes the recipient's motor development just prior to the time of transplant.

Definite Motor Delay/Impairment (verified by physical exam or unambiguous behavioral observation)

Probable Motor Delay/Impairment (not verified or unambiguous but more likely than not, based on behavioral observation or other evidence)

Questionable Motor Delay/Impairment (not judged to be more likely than not, but with some indication of motor delay/impairment)

No Motor Delay/Impairment (no obvious indicators of motor delay/impairment)

Not Assessed

Working for income: (This field is required for recipients 19 years of age or older.) If the recipient was working for income just prior to the time of transplant, select Yes. If not, select No. If reporting the recipient's death, indicate if the recipient was working for income just prior to death.

Academic Progress: (This field is required for recipients less than 18 years of age.) Select the choice that best describes the recipient's academic progress just prior to the time of transplant. If the recipient is less than 5 years old or has graduated from high school, select Not Applicable < 5 years old/High School graduate or GED.

Within One Grade Level of Peers
Delayed Grade Level
Special Education
Not Applicable <5 years old/High School graduate or GED
Status Unknown

Academic Activity Level: (This field is required for recipients less than 18 years of age.) Select the choice that best describes the recipient's academic activity level just prior to the time of transplant. If the recipient is less than 5 years old or has graduated from high school, select Not Applicable < 5 years old/High School graduate or GED.

Full academic load
Reduced academic load
Unable to participate in academics due to disease or condition
Unable to participate regularly in academics due to dialysis
Not Applicable <5 years old/High School graduate or GED
Status Unknown

Source of Payment:

Primary: Select as appropriate to indicate the recipient's source of primary payment (largest contributor) for the transplant. This field is required.

Private insurance refers to funds from agencies such as Blue Cross/Blue Shield, etc. It also refers to any worker's compensation that is covered by a private insurer.

Public insurance - Medicaid refers to state Medicaid funds.

Public insurance - Medicare FFS (Fee-for-Service) refers to funds from the government in which doctors and other health care providers are paid for each service provided to a recipient. For additional information about Medicare, see http://www.medicare.gov/Choices/Overview.asp.

Public insurance - Medicare & Choice (also known as Medicare Managed Care) refers to funds from the government in which doctors and other health care providers are paid for each service provided to a recipient, along with additional benefits such as coordination of care or reducing-out-of-pocket expenses. Sometimes a recipient may receive additional benefits such as prescription drugs. For additional information about Medicare, see http://www.medicare.gov/Choices/Overview.asp.

Public insurance - CHIP (Children's Health Insurance Program)

Public insurance - Department of VA refers to funds from the Veterans Administration.

Public insurance - Other government

Self indicates that the recipient will pay for the cost of transplant.

Donation indicates that a company, institution, or individual(s) donated funds to pay for the transplant and care of the recipient.

Free Care indicates that the transplant hospital will not charge recipient for the costs of the transplant operation.

Foreign Government, Specify refers to funds provided by a foreign government (Primary only) Specify foreign country in the space provided. (List of Foreign Country codes – See Appendix E)

Date of Measurement: (Complete for recipients 18 years of age or younger.) Enter the date, using the 8-digit format of MM/DD/YYYY, the recipient’s height and weight were measured.

Height: Enter the height of the recipient, just prior to the time of transplant, in feet and inches or centimeters. If the recipient’s height is unavailable, select the appropriate status from the ST field (Missing, Unknown, N/A, Not Done).) For recipients 18 years old or younger at the time of transplant, UNet will generate and display calculated percentiles based on the 2000 CDC growth charts. This field is required.

Weight: Enter the weight of the recipient, just prior to the time of transplant, in pounds or kilograms. If the recipient’s weight is unavailable, select the appropriate status from the ST field (Missing, Unknown, N/A, Not Done). For recipients 18 years old or younger at the time of transplant, UNet will generate and display calculated percentiles based on the 2000 CDC growth charts. This field is required.

BMI (Body Mass Index): The recipient's BMI will display. For candidates less than 20 years of age at the time of transplant, UNet will generate and display calculated percentiles based on the 2000 CDC growth charts.

Percentiles are the most commonly used clinical indicator to assess the size and growth patterns of individual children in the United States. Percentiles rank the position of an individual by indicating what percent of the reference population the individual would equal or exceed (i.e. on the weight-for-age growth charts, a 5 year-old girl whose weight is at the 25th percentile, weighs the same or more than 25 percent of the reference population of 5-year-old girls, and weighs less than 75 percent of the 5-year-old girls in the reference population). For additional information about CDC growth charts, see http://www.cdc.gov/.

Note: Users who check the BMI percentiles against the CDC calculator may notice a discrepancy that is caused by the CDC calculator using 1 decimal place for height and weight and UNet using 4 decimal places for weight and 2 for height.

Previous Transplants: The three most recent transplant(s), indicated on the recipient's validated Transplant Recipient Registration (TRR) record(s), will display. Verify all previous transplants listed by organ type, transplant date and graft failure date.

Note: The three most recent transplants on record for this recipient will be displayed for verification. If there are any prior transplants that are not listed here, contact the UNet Help Desk at 1-800-978-4334 or [email protected] to determine if the transplant event is in the database.

Viral Detection:

HIV Serostatus: Select the serology results from the drop-down list. This field is required.