CMS-10390 Hospice Item Set - Discharge

OMB Control Number: 0938-1153
Expiration Date: XX-XX-XXXX

Hospice Item Set – Discharge
Section A

Administrative Information

A0050. Type of Record
Enter Code

1. Add new record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers. Enter code in boxes provided.
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

A0220. Admission Date

Month

A0250. Reason for Record
Enter Code

Day

Year

Day

Year

01. Admission
09. Discharge

A0270. Discharge Date
Month

A0500. Legal Name of Patient
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

Hospice Item Set – Discharge
V2.00.0 Effective April 1, 2017

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Section A

Administrative Information

A0600. Social Security and Medicare Numbers
A. Social Security Number:

-

-

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid Recipient
A0800. Gender
Enter Code

1. Male
2. Female

A0900. Birth Date

Month

A2115. Reason for Discharge
Enter Code

Day

Year

01. Expired
02. Revoked
03. No longer terminally ill
04. Moved out of hospice service area
05. Transferred to another hospice
06. Discharged for cause

Hospice Item Set – Discharge
V2.00.0 Effective April 1, 2017

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Section O

Service Utilization

O5000. Level of care in final 3 days
Complete only if A2115, Reason for Discharge = 01 Expired
Enter Code

Did the patient receive Continuous Home Care, General Inpatient Care, or Respite
Care during any of the final 3 days of life?
0. No
1. Yes  Skip to Z0400, Signature(s) of Person(s) Completing the Record

O5010. Number of hospice visits in final 3 days
Enter the number of visits provided by hospice staff from the indicated discipline, on
each of the dates indicated.
Visits on day
of death
(A0270)

Visits one day
prior to death
(A0270
minus 1)

Visits two days
prior to death
(A0270
minus 2)

A. Registered Nurse
B. Physician (or Nurse Practitioner or
Physician Assistant)
C. Medical Social Worker
D. Chaplain or Spiritual Counselor
E. Licensed Practical Nurse
F. Aide

O5020. Level of care in final 7 days
Complete only if A2115, Reason for Discharge = 01 Expired
Enter Code

Did the patient receive Continuous Home Care, General Inpatient Care, or Respite
Care during any of the final 7 days of life?
0. No
1. Yes  Skip to Z0400, Signature(s) of Person(s) Completing the Record

O5030. Number of hospice visits in 3 to 6 days prior to death
Enter the number of visits provided by hospice staff from the indicated discipline, on
each of the dates indicated.
Visits three
days prior to
death (A0270
minus 3)

Visits four
days prior to
death (A0270
minus 4)

Visits five days
prior to death
(A0270
minus 5)

Visits six days
prior to death
(A0270
minus 6)

A. Registered Nurse
B. Physician (or Nurse
Practitioner or Physician
Assistant)
C. Medical Social Worker
D. Chaplain or Spiritual
Counselor
E. Licensed Practical Nurse
F. Aide
Hospice Item Set – Discharge
V2.00.0 Effective April 1, 2017

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Section Z

Record Administration

Z0400. Signature(s) of Person(s) Completing the Record
I certify that the accompanying information accurately reflects patient assessment
information for this patient and that I collected or coordinated collection of this information on
the dates specified. To the best of my knowledge, this information was collected in accordance
with applicable Medicare and Medicaid requirements. I understand that reporting this
information is used as a basis for payment from federal funds. I further understand that failure to
report such information may lead to a 2 percentage point reduction in the Fiscal Year payment
determination. I also certify that I am authorized to submit this information by this provider on its
behalf.
Signature

Title

Sections

Date Section
Completed

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Z0500. Signature of Person Verifying Record Completion
A. Signature:

____________________________________________________

B. Date:

Month

Day

Year

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0938-1153. The time required to complete this
information collection is estimated to average 14 minutes per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Hospice Item Set – Discharge
V2.00.0 Effective April 1, 2017

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