Cms-p-0015a Mcbs

Outpatient Utilization (OPQ)
Variable Name
MR Screen Name
OPPROBE
OP1

Question type
yes/no

Question text/description
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDTUILD)], [have you gone/has (SP) gone/did (SP) go] to the outpatient department
or the outpatient clinic at any hospital for medical care?

PROVIDER_OP

roster

Where did [you/(SP)] go (to which hospital)?
SELECT OR ADD ONLY ONE HOSPITAL.

OP2

[PROBE TO OBTAIN THE COMPLETE AND FORMAL NAME OF THE HOSPITAL.]
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]

PROVNAME

OP2

Code list
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.

verbatim
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

NAME:
GROUPNAM

OP2
BOX OP1

verbatim
routing

GROUP:
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO OP3 - VAPLACE.
ELSE GO TO BOX OP1B.

VAPLACE

OP3

yes/no

Is (HOSPITAL NAME) a Department of Veterans Affairs, or V.A., facility?

BOX OP1B

routing

HMOASSOC

OP3A

yes/no

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO OP3A - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO OP3B - HMOREFER.
ELSE GO TO OP4 - EVENT_OP
Is (HOSPITAL NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

OP3B

yes/no

[Were you/Was (SP)] referred to (HOSPITAL NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Outpatient Utilization (OPQ)
Variable Name
MR Screen Name
EVENT_OP
OP4

Question type
roster

Question text/description
When did [you/(SP)] go to an outpatient department at (HOSPITAL NAME)? Please tell me all the dates [since
(REFERENCE DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.

Code list
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS

[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
OPADD

HAVE ALL DATES BEEN ENTERED?

NAVIGATOR

OP4_IN

instance navigator

ANYOPERS

OP5

yes/no

SPECCOND

OP8

yes/no

BOX OP2A

routing

PRESMDCN

OP10

yes/no

PRESFILL

OP11

yes/no

BOX OP2B

routing

OP11A

no entry

OPPMMEDS

(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS (01) EVENT1
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) EVENT2
…
[DISPLAY ALL EVENTS ADDED AT ER6]
(N) EVENT N
[EVENT DATE, PROVIDER]
(N+1) CONTINUE INTERVIEW
Were any operations or other surgical procedures performed on [you/(SP)] during [any of the/the] [VISIT ON (01) YES
EVENT DATE]?
(02) NO
(-8) Don't Know
[Operations include surgery and other surgical procedures like setting bones, stitching or removing growths, (-9) Refused
or any cutting of the skin.]
[Was this visit/Were any of these visits] to the outpatient department for any specific condition?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE GO TO OP10 - PRESMDCN.
During [this visit/any of these visits] to the outpatient department, were any medicines prescribed for
(01) YES
[you/(SP)]?
(02) NO
(-8) Don't Know
(-9) Refused
Were any of the prescriptions filled?
(01) YES
(02) NO
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN IT WAS (-8) Don't Know
OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
(-9) Refused
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO TO
OP11A - OPPMMEDS.
ELSE GO TO OP12 - MEDICINE_OP.
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.

Outpatient Utilization (OPQ)
Variable Name
MR Screen Name
MEDICINE_OP
OP12

Question type
roster

Question text/description
Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE EVENT.EVNTTYPE='PM' AND
EVNTDFLG^=1)]
DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)

Code list
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR EACH.
IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES
LISTED"]

MED

OP12

verbatim

[AT TOP OF SCREEN DISPLAY LINK TO PRESCRIBED MEDICINE LOOKUP WITH LABEL "Search Medicine"]
Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE EVENT.EVNTTYPE='PM' AND
EVNTDFLG^=1)]
DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)

PMEDNAME
PMSTRUNI
ADDP

OPMORE

OP12
OP12
OP12B

verbatim
verbatim
roster

BOX OP3
OP15

routing
yes/no

BOX OP6

routing

BOX OP7

routing

MEDICATIONS FILLED DURING THIS VISIT

(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL MEDICINES ADDED AT MED]
GO TO OP4_IN - NAVIGATOR.
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to the outpatient department at this (02) NO
or any other hospital for services?
(-8) Don't Know
(-9) Refused
IF FALL ROUND AND ((SP REPORTED AN OUTPATIENT DEPARTMENT VISIT AT OP4) AND (SP IS ALIVE AND NOT
INSTITUTIONALIZED)), GO TO AC9 - OPDREAS.
ELSE GO TO BOX OP7.
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