Cms-p-0015a Mcbs

Dental Utilization (DUQ)
MR Screen
Variable Name
Name

Question type

Question text/description
The next questions are about any medical care [you/(SP)] may have had between
(REFERENCE DATE/UTILDATE) and (today/DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD).

DUINT

no entry

(Now would be a good time to get out the planner that [you/(SP)] may have used to
record health care visits or other medical expenses. We will also refer to any
statements you may have received since the last interview.)

DUINTRO

Code list

First we’ll talk about dental care.

DUPROBE

DU1

yes/no

PROVIDER_DU

DU2

roster

PROVNAME

DU2B

verbatim text

(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF
(02) NO
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a dentist or
(03) INDICATED YES BY DATAPREP
any other person for dental care? [Dental providers include dentists, dental surgeons,
(-8) Don't Know
endodontists, periodontists, and dental hygienists.]
(-9) Refused
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
Who did [you/(SP)] see?
…
SELECT OR ADD ONLY ONE PROVIDER.
(01-N) LIST ALL PROVIDERS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME FOR ALL
PROVIDERS WHERE PROVNUM>02.
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME
BELOW.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:

GRPNAME

DU2B

verbatim text

GROUP:

PROVSPEC

DU2C

code one

What kind of dental provider is [PROVNAME]?

PROVSPECOTH

DU2C

code one

What kind of dental provider is [PROVNAME]?

PROVSPOS

DU2D

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIDONTIST
(41) PROSTHODONTIST
(09) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(01) [Continuous answer.]

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Dental Utilization (DUQ)
MR Screen
Variable Name
Name

Question type

BOX DU1

routing

DU3

yes/no

BOX DU2

routing

HMOASSOC

DU4

yes/no

HMOREFER

DU5

yes/no

EVENT_DU

DU6

roster

DUADD

DU6B

chose one

NAVIGATOR

DU6_IN

instance navigator

VAPLACE

Question text/description
Code list
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 DU3 - VAPLACE.
ELSE GO TO BOX DU2.
(01) YES
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A.,
(02) NO
facility?
(-8) Don't Know
(-9) Refused
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 DU4 - 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 DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.
(01) YES
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN
(02) NO
NAME(S) BELOW] plan?
(-8) Don't Know
(-9) Refused
(01) YES
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN
(02) NO
NAME(S) BELOW]?
(-8) Don't Know
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(-9) Refused
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since
(01) continuous answer
(REFERENCE DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF
(-8) Don't Know
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)].
(-9) Refused
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER
MM:
THE DATE ONLY ONCE.]
DD:
YYYY:
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD,
REPEAT VISIT: YES/NO
SELECT "REPEAT VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH
# OF VISITS
SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
(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
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
DISCUSS WITH SP OR PRESS [PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) CONTINUE INTERVIEW SELECTED
(N) EVENT N
[DISPLAY ALL EVENTS ADDED AT DU6]
(N+1) CONTINUE INTERVIEW
[EVENT DATE, PROVIDER]

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Dental Utilization (DUQ)
MR Screen
Variable Name
Name

Question type

Question text/description

SHOW CARD DU1
DVPROCDR

DU7

code all

For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.

EVOSTEXT

DU7A

verbatim text

OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)

PRESMDCN

DU9

yes/no

Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?

PRESFILL

DUPMMEDS

DU10

yes/no

BOX DU3B

routing

DU10A

no entry

Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE
RESPONDENT, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND
WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE
CURRENT ROUND, GO TO DU10A - DUPMMEDS.
ELSE GO TO DU11 - MEDICINE_DU.
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.]

Code list
(01) GENERAL EXAM, CHECKUP OR CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR GUM
SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) [CONTINUOUS ANSWER]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) INSTRUCTION WAS READ

[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.

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Dental Utilization (DUQ)
MR Screen
Variable Name
Name

Question type

Question text/description

Code list
(01) continuous answer

MEDICINE_DU
MEDLIST

Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.
DU11

roster
[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE
EVENT.EVNTTYPE='PM' AND EVNTDFLG^=1)]

[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.

DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)
IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES LISTED"]
[DISPLAY LINK TO PRESCRIBED MEDICINE LOOKUP WITH LABEL "Search Medicine"]

MED

Please tell me the names of these medicines.
ENTER ALL MEDICINES.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
INCLUDE STRENGTH WITH NAME.

DU11

[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

DU11
DU11

verbatim
verbatim

ADDP

DU11B

roster

NAME:
STRENGTH:
MEDICATIONS FILLED DURING THIS VISIT
[DISPLAY ALL MEDICINES ADDED AT DU11-MED]
GO TO DU6_IN - NAVIGATOR.

BOX DU4

routing

(01) ADD ANOTHER
(02) ALL DONE

[LOOP THROUGH ALL DETAILED QUESTIONS FOR EACH EVENT BEFORE CONTINUING
TO DU14]

DUMORE

DU14

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other
dental care visits to this or any other provider?

DVNEED

DU15

yes/no

Since (REFERENCE DATE), was there a time when {you/SP} needed dental care but
could not get it at that time?

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

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Dental Utilization (DUQ)
MR Screen
Variable Name
Name

Question type

Question text/description

DVNDRS

DU16

code all

What were the reasons that {you/SP} could not get the dental care {you/she/he}
needed?

DVNDRSOS

DU16A
BOX DU6

verbatim text
routing

WHAT OTHER REASON (SPECIFY)
GO TO NEXT SECTION

Code list
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT DOING IT
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO AWAY
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer

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