Cms-p-0015a Mcbs

End (END)
Variable Name

MR Screen Name

Question type

SUMINTRO

SUM1

code one

SUMEDITTYPE

SUM2

code one

SUMITEMTYPE

SUM3

code one

SUMMETYPE

SUM4

code one

SUMDOCLIST

SUM5

code one

SUMDOCSELECT
SUMDOCNAME

SUM6
SUM7

code one
verbatim

SUMRXLIST

SUM8

code one

SUMRXSELECT
SUMRXNAME

SUM9
SUM10

code one
verbatim

Question text/description
Code list
ARE THERE ANY MEDICAL EVENTS, HEALTH INSURANCE PLANS, OR PRESCRIPTION MEDICINES THAT NEED TO (1) YES
BE ADDED OR DELETED FOR THE CURRENT ROUND?
(2) NO
(-8) DON'T KNOW
PROBE FOR DETAILS IF NECESSARY.
(-9) REFUSED
(1) ADD AN ITEM
DOES AN ITEM NEED TO BE ADDED OR DELETED?
(2) DELETE AN ITEM
(1) A MEDICAL EVENT
WHAT TYPE OF ITEM NEEDS TO BE [ADDED/DELETED]?
(2) A PRECRIPTION DRUG
(3) A HEALTH INSURANCE
(1) DENTAL EVENT
(2) INPATIENT EVENT
(3) OUTPATIENT EVENT
(4) MEDICAL PROVIDER EVENT
WHAT TYPE OF MEDICAL EVENT WAS IT?
(5) OTHER MEDICAL EVENT
(6) INSTITUTIONAL EVENT
(7) HOME HEALTH EVENT
(8) EMERGENCY ROOM EVENT
DOES THE DOCTOR OR HOSPITAL NAME ASSOCIATED WITH THIS EVENT APPEAR ON THE LIST BELOW?
(1) YES
(2) NO
[DISPLAY LIST OF ALL HOSPITALS/DOCTORS FOR THIS SP]
SELECT THE DOCTOR OR HOSPITAL NAME ASSOCIATED WITH THIS EVENT FROM THE LIST BELOW.
SEE NOTES
TYPE THE NAME OF THE DOCTOR OR HOSPITAL.
(1) CONTINUOUS ANSWER
DOES THE PRESCRIPTION MEDICINE APPEAR ON THE LIST BELOW?
(1) YES
(2) NO
[DISPLAY LIST OF ALL PRESCRIPTION MEDICINE NAMES FOR THIS SP]
SELECT THE PRESCRIPTION MEDICINE FROM THE LIST BELOW.
SEE NOTES
TYPE THE NAME OF THE PRESCRIPTION MEDICINE.
(1) CONTINUOUS ANSWER

SUM11

code one

IN WHAT FORM IS THE MEDICINE?

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS, DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10) PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) DON'T KNOW

SUMRXFORMOTH SUM12

verbatim

OTHER (SPECIFY)

(1) CONTINUOUS ANSWER

SUMRXFORM

End (END)
Variable Name

MR Screen Name

Question type

Question text/description

SUMSTRUNIT

SUM13

code one

WHAT WAS THE UNIT OF THE STRENGTH OF THE MEDICINE?

SUMSTRUNITOTH SUM14
SUMTABTAKE
SUM15

verbatim
numeric

OTHER (SPECIFY)
HOW MANY [PILLS/SUPPOSITORIES] ARE TO BE TAKEN IN A DAY?

SUMHITYPE

SUM16

code one

WHAT TYPE OF HEALTH INSURANCE PLAN NEEDS TO BE [ADDED/DELETED]?

SUMHINAME

SUM17

verbatim

WHAT IS THE NAME OF THE HEALTH INSURANCE PLAN?

SUMHIPLANSTART SUM18

date

ON WHAT DATE DID COVERAGE BEGIN FOR THIS HEALTH INSURANCE PLAN?

SUMHIPLANCOVER SUM19

code one

IS THE SP STILL COVERED BY THIS HEALTH INSURANCE PLAN AS OF THE DATE OF THIS INTERVIEW?

SUMHIPLANEND

SUM20

date

ON WHAT DATE DID COVERAGE STOP?

SUMDATEMM

SUM21

date

WHAT WAS THE DATE [OF THE MEDICAL EVENT/THE PRESCRIPTION WAS FILLED]?

SUMDATEDD

SUM21

date

WHAT WAS THE DATE [OF THE MEDICAL EVENT/THE PRESCRIPTION WAS FILLED]?

SUMDATEYY

SUM21

date

WHAT WAS THE DATE [OF THE MEDICAL EVENT/THE PRESCRIPTION WAS FILLED]?

SUMENDLOOP

SUM22

code one

ARE THERE ANY MORE MEDICAL EVENTS, HEALTH INSURANCE PLANS, OR PRESCRIPTION MEDICINES THAT
NEED TO BE ADDED OR DELETED FOR THIS ROUND?

INTLANG

END1

code 1

WAS THIS INTERVIEW CONDUCTED MOSTLY IN ENGLISH OR
SPANISH?

Code list
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
COMBINED DO NOT DISPLAY.
(-8) Don't Know
(1) CONTINUOUS ANSWER
(1) CONTINUOUS ANSWER
(1) MEDICARE
(2) MEDICARE MANAGED CARE PLAN
(3) MEDICAID
(4) TRICARE
(5) PRIVATE PLAN
(6) PUBLIC PLAN (OTHER THAN MEDICAID)
(7) MEDICARE PRESCRIPTION DRUG PLAN
(1) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(1) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(1) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(1) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(1) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(1) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(1) YES
(2) NO
(02) ENGLISH
(03) SPANISH
(91) OTHER

End (END)
Variable Name

MR Screen Name

Question type

SAVECASE

END2

no entry

BOX END

routing

Question text/description
(Someone from the home office may be calling to verify that I was here to conduct this interview.)
THIS CASE IS CODED (CASE RESULT CODE) (CASE DISPOSITION) (CASE EXPLAINATION).
PRESS ENTER TO COMPLETE THE INTERVIEW.
CASE IS COMPLETE. RETURN TO IMS

Code list
(01) CONTINUE
(-7) Empty