Cms-p-0015a Mcbs

Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
MPPRMDOC
MP1

PROVIDER_MP

MP2

Question type
yes/no

roster

Question text/description
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] [seen/see] any medical doctors?
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
SEE SHOWCARD AC1 FOR TYPES OF MEDICAL DOCTORS, IF NECESSARY.
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.

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

(01) [Continuous answer.]
[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.

PROVNAME

MP2

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

GROUPNAM

MP2
BOX MP1B

routing

GROUP:
IF (PROVIDER IS A MEDICAL PLACE) OR (PROVIDER SPECIALTY HAS ALREADY BEEN COLLECTED), GO TO BOX
MP1.
ELSE GO TO MP2A - PROVSPEC.

Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
PROVSPEC
MP2A

Question type
code 1

Question text/description
What kind of (health practitioner/mental health professional/therapist/medical person) is (PROVIDER
NAME)?

Code list
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES (04) CHIROPRACTOR
THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT PROVIDER (05) CLINICAL SOCIAL WORKER
SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED ON
(06) DIETITIAN-NUTRITIONIST
SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
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 MP3 - VAPLACE.
ELSE GO TO BOX MP2.

PROVSPOS

MP2A
BOX MP1

verbatim text
routing

VAPLACE

MP3

yes/no

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

BOX MP2

routing

HMOASSOC

MP4

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 MP4 - 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 MP5 - HMOREFER.
ELSE GO TO MP6 - EVENT.
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

HMOREFER

MP5

yes/no

[Were you/Was (SP)] referred to (PROVIDER 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

Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
EVENT
MP6

Question type
roster

Question text/description
When did [you/(SP)] see (PROVIDER 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
(01) [Continuous answer.]
(

[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.
MPADD

NAVIGATOR

MP6

MP6_IN

choose one

HAVE ALL DATES BEEN ENTERED?

instance navigator

[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) ITEM SELECTED IN INSTANCE NAVIGATOR
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) CONTINUE INTERVIEW SELECTED

BOX MP2AA

routing

MP6B

yes/no

BOX MP2B
BOX MP2C

routing
routing

ANYOPERS

MP7

yes/no

SPECCOND

MP10

yes/no

BOX MP2D

routing

PRESMDCN

MP12

yes/no

PRESFILL

MP13

yes/no

MPSDVIS

(01) ADD ANOTHER
(02) ALL DONE

[DISPLAY ALL EVENTS ADDED AT ER6]
[EVENT DATE, PROVIDER]
FOR FIRST/NEXT EVENT ENTERED AT MP6, IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT
DATE OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE MATCHES AN EXISTING ER OR OP EVENT), GO TO
MP6B - MPSDVIS.
ELSE GO TO BOX MP2C.
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in (READ EVENT(S) LISTED BELOW). Was (01) YES
this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED BELOW]/any (02) NO
of these places]?
(-8) Don't Know
(-9) Refused
UPDATE EVENT TYPE TO SEPARATELY BILLING DOCTOR AND GO TO BOX MP6.
IF PROVIDER SPECIALTY = Dentist, Medical Doctor, Optometrist, Osteopath, Paramedic, PhysicianAssistant,
Podiatrist, Other, DK or RF, GO TO MP7 - ANYOPERS.
ELSE GO TO MP10 - SPECCOND.
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 (PROVIDER NAME) 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 MP12 - PRESMDCN.
During [this visit/any of these visits] to (PROVIDER NAME), were any medicines prescribed for [you/(SP)]?
(01) YES
(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.]

Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
BOX MP3A

Question type
routing

MPPMMEDS

no entry

MEDICINE_MP

MP13A

MP14

roster

Question text/description
Code list
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO TO
MP13A - MPPMMEDS.
ELSE GO TO MP14 - MEDICINE_MP.
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 (01) CONTINUE
spell the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (-7) Empty
(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.
Please tell me the names of these medicines.
ENTER ALL MEDICINE NAMES.
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)

(01) [Continuous answer.]
[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

MP14

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.

PMEDNAME
PMSTRUNI
ADDP

MP14
MP14
MP14B

verbatim
verbatim
roster

BOX MP6
BOX MP6AA

routing
routing

[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE EVENT.EVNTTYPE='PM' AND
EVNTDFLG^=1)]
DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)
NAME:
STRENGTH:
MEDICATIONS FILLED DURING THIS VISIT
[DISPLAY ALL MEDICINES ADDED AT MED]
GO TO MP6_IN - NAVIGATOR.
IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP1 PROBE, GO TO MP17 - MDOCMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP18 PROBE, GO TO MP25 - PRACMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP26 PROBE, GO TO MP33 - MENTMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP34 PROBE, GO TO MP41 - THERMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP42 PROBE, GO TO MP49 - PERSMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP50 PROBE, GO TO MP56 - MPPRMORE.

(01) ADD ANOTHER
(02) ALL DONE

Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
MDOCMORE
MP17

MPPRPRAC

Question type
yes/no

BOX MP6A

routing

MP18

yes/no

Question text/description
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this doctor or any other medical
doctor?
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
IF FALL ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED) AND (SP REPORTED A MEDICAL PROVIDER
VISIT AT MP6 AND MP6B - MPSDVIS ^= 1/Yes AND PROVIDER'S SPECIALTY IS A MEDICAL DOCTOR), GO TO
AC20 - MDSPCLTY.
ELSE GO TO MP18 - MPPRPRAC.
SHOW CARD MP1
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] [seen/see] a health practitioner like any of the ones listed on this card? [Health practitioners
include acupuncturist, audiologist, optometrist, chiropractor, podiatrist (foot doctor), homeopath,
naturopath, or any other kind of health provider who is not a medical doctor.]
INCLUDE ANY VISITS FOR TESTS/X-RAYS.

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

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

[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
PRACMORE

MPPRMENT

MP25

MP26

yes/no

yes/no

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

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

[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
SHOW CARD MP2

(01) YES
(02) NO
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between) (-8) Don't Know
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(-9) Refused
(SP)/did (SP)] (seen/see) a mental health professional like any of the ones listed on this card? [Mental health
professional includes psychiatrist, psychologist, clinical social worker, and licensed professional counselor.]
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

MENTMORE

MP33

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this professional or any other
mental health professional?
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

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

Medical Provider Utilization (MPQ)
Variable Name
MR Screen Name
MPPRTHER
MP34

THERMORE

MP41

Question type
yes/no

yes/no

MPPRPERS

MP42

yes/no

PERSMORE

MP49

yes/no

MPPRPLAC

MP50

yes/no

Question text/description
SHOW CARD MP3
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] (seen/see) a therapist like any of the ones listed on this card? [Therapist includes physical
therapist, speech therapist, intravenous (IV) therapist, massage therapist, occupational therapist, and
respiratory therapist.]
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this therapist or any other
therapist?
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
SHOW CARD MP4
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] (seen/see) any other medical persons like the ones listed on this card? [Other medical persons
include nurse, nurse practitioner, paramedic, and physician’s assistant.]
[INCLUDE ANY VISITS FOR TESTS/X-RAYS.
DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.
DO NOT INCLUDE PARAMEDIC IF ONLY AMBULANCE SERVICES WERE PROVIDED.]
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/ENDUTILD], did [you/(SP)] have any other visits to this person or any other medical
person?
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
SHOW CARD MP5
(Besides what you have already mentioned), [(Since/since (REFERENCE
DATE/UNTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD), [have you/has (SP)/did (SP)] (visited/visit) any other types of medical
places like the ones listed on this card? [Other types of medical places include health clinic, neighborhood
health center, rural health clinic, infirmary, mental health clinic, urgent care center, or any other place.]

Code list
(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

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

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

[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM, OUTPATIENT DEPARTMENTS, INPATIENT STAYS, OR
SENIOR DAY CARE.]
MPPRMORE

MP56

BOX MP22

yes/no

routing

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this place or any other type of
medical place?
[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM, OUTPATIENT DEPARTMENTS, INPATIENT STAYS, OR
SENIOR DAY CARE.]
GO TO NEXT SECTION (OMQ)

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