CMS-10387 Proposed Data Elements (60.5 New Elements)

Proposed SNF QRP New and Modified Items
Effective Date: October 1, 2020
ADMISSION (Start of SNF Stay)
Section A

Identification Information

A1005. Ethnicity
Are you Hispanic, Latino/a, or Spanish origin?
Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, Another Hispanic, Latino, or Spanish origin
X. Resident unable to respond
A1010. Race
What is your race?
Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I. Vietnamese
J. Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Resident unable to respond

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

A1110. Language
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed
for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I
need
C. No
D. Resident unable to respond
A1805. Entered From
Enter Code

01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section B

Hearing, Speech, and Vision

B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
Enter Code

Section D

0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
5. Resident unable to respond

Mood

D0150. Resident Mood Interview (PHQ-2 to 9)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2,
Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence
Frequency
9. No response (leave column 2 blank)
2. 7-11 days (half or more of the
days)
Enter Scores in Boxes
3. 12-14 days (nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the
PHQ interview and SKIP to next section.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let
yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or
watching television
H. Moving or speaking so slowly that other people could have noticed. Or
the opposite—being so fidgety or restless that you have been moving
around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in
some way
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

D0160. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be
between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required
items)
D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Resident unable to respond

Section J

Health Conditions

J0510. Pain Effect on Sleep
Enter Code
Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer
J0520. Pain Interference with Therapy Activities
Ask resident: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer
J0530. Pain Interference with Day-to-Day Activities
Enter Code
Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer
Enter Code

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that were performed on admission
On Admission
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet – require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the resident is taking any medications in the
following drug classes by pharmacological
classification, not how it is used
2. Indication noted
If Column 1 is checked, check if there is an indication
noted for all medications in the drug class

1. Is taking

2. Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
B. Antianxiety
C. Antidepressant
D. Hypnotic
E. Anticoagulant
F. Antibiotic
G. Diuretic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that
were performed on admission

On Admission
Check all that apply

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that
were performed on admission

On Admission
Check all that apply

J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

PLANNED DISCHARGE (End of SNF Stay)
A0310G =1

Section A

Identification Information

A1110. Language
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things
that I need
C. No
D. Resident unable to respond
A2105. Discharge Status
Complete only if A0310F = 10, 11, or 12
Enter Code
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the resident’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

A2122. Provision of Current Reconciled Medication List to Resident at Discharge
At the time of discharge, did your facility provide the resident’s current reconciled medication list to the
resident, family and/or caregiver?
Enter Code
0. No – Current reconciled medication list not provided to the resident, family and/or
caregiver
1. Yes – Current reconciled medication list provided to the resident, family and/or
caregiver
A2123. Route of Current Reconciled Medication List Transmission
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
and/or resident/family/caregiver.
1.
2.
To subsequent
To resident/family/
Route of Transmission
provider
caregiver
Check all that apply
A. Electronic Health Record
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section B

Hearing, Speech, and Vision

B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Resident unable to respond

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents
Enter Code

0. No (resident is rarely/never understood)  Skip to XXXX
1. Yes  Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code Ask resident: “I am going to say three words for you to remember. Please repeat the words after I
have said all three. The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the resident’s first attempt, repeat the words using cues (“sock, something to wear; blue, a
color; bed, a piece of furniture”). You may repeat the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Enter Code Ask resident: “Please tell me what year it is right now.”
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Enter Code Ask resident: “What month are we in right now?”
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Ask resident: “What day of the week is today?”
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct
C0400. Recall
Enter Code Ask resident: “Let's go back to an earlier question. What were those three words that I asked you to
repeat?” If unable to remember a word, give cue (something to wear; a color; a piece of furniture)
for that word.
A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
Enter Code B. Able to recall “blue”
0. No - could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
Enter Code
C. Able to recall “bed”
0. No - could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required
C0500. BIMS Summary Score
Enter Code

Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the resident was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
A. Acute Onset Mental Status Change
Enter Code
Is there evidence of an acute change in mental status from the resident’s baseline?
0. No
1. Yes
Enter Code in Boxes
Coding:
B. Inattention – Did the resident have difficulty focusing attention, for
0. Behavior not present
example being easily distractible or having difficulty keeping track of
1. Behavior
what was being said?
continuously
C. Disorganized thinking – Was the resident’s thinking disorganized or
present, does not
incoherent (rambling or irrelevant conversation, unclear or illogical
fluctuate
flow of ideas, or unpredictable switching from subject to subject)?
2. Behavior present,
D. Altered level of consciousness – Did the resident have altered level of
fluctuates (comes
consciousness as indicated by any of the following criteria?
and goes, changes in
• vigilant – startled easily to any sound or touch
severity)
• lethargic – repeatedly dozed off when being asked questions, but
responded to voice or touch
• stuporous – very difficult to arouse and keep aroused for the
interview
• comatose – could not be aroused
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Confusion Assessment Method ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from:
Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

Section D

Mood

D0150. Resident Mood Interview (PHQ-2 to 9)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2,
Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence
Frequency
9. No response (leave column 2 blank)
2. 7-11 days (half or more of the
days)
Enter Scores in Boxes
3. 12-14 days (nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the
PHQ interview and SKIP to next section.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let
yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or
watching television
H. Moving or speaking so slowly that other people could have noticed. Or
the opposite – being so fidgety or restless that you have been moving
around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in
some way
D0160. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be
between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required
items)

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Resident unable to respond

Section J

Health Conditions

J0510. Pain Effect on Sleep
Enter Code
Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer
J0520. Pain Interference with Therapy Activities
Ask resident: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer
J0530. Pain Interference with Day-to-Day Activities
Enter Code
Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer
Enter Code

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
While a Resident
Performed while a resident of this facility and within the last 7
days

1. While a
Resident

At Discharge

2. At Discharge

Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet – require change in texture of food
or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section N

Medications

N0420. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the resident is taking any medications in the
following drug classes by pharmacological
classification, not how it is used
2. Indication noted
If Column 1 is checked, check if there is an indication
noted for all medications in the drug class

1. Is taking

2. Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
B. Antianxiety
C. Antidepressant
D. Hypnotic
E. Anticoagulant
F. Antibiotic
G. Diuretic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that
were performed at discharge

At Discharge
Check all that apply

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that
were performed at discharge

At Discharge
Check all that apply

J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

UNPLANNED DISCHARGE (End of SNF Stay)
A0310G =2
Section A

Identification Information

A2105. Discharge Status
Complete only if A0310F = 10, 11, or 12
Enter Code
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the resident’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

A2122. Provision of Current Reconciled Medication List to Resident at Discharge
At the time of discharge, did your facility provide the resident’s current reconciled medication list to the
resident, family and/or caregiver?
Enter Code
0. No – Current reconciled medication list not provided to the resident, family and/or
caregiver
1. Yes – Current reconciled medication list provided to the resident, family and/or
caregiver

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

A2123. Route of Current Reconciled Medication List Transmission
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
and/or resident/family/caregiver.
1.
2.
To subsequent
To resident/family/
Route of Transmission
provider
caregiver
Check all that apply
A. Electronic Health Record
B. Health Information Exchange Organization
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E. Other Methods (e.g., texting, email, CDs)

Section C

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after evaluating cognitive status and reviewing medical record.
A. Acute Onset Mental Status Change
Enter Code
Is there evidence of an acute change in mental status from the resident’s baseline?
0. No
1. Yes
Enter Code in Boxes
Coding:
B. Inattention – Did the resident have difficulty focusing attention, for
0. Behavior not
example being easily distractible or having difficulty keeping track of
present
what was being said?
1. Behavior
C. Disorganized thinking – Was the resident’s thinking disorganized or
continuously
incoherent (rambling or irrelevant conversation, unclear or illogical
present, does not
flow of ideas, or unpredictable switching from subject to subject)?
fluctuate
D. Altered level of consciousness – Did the resident have altered level of
2. Behavior present,
consciousness as indicated by any of the following criteria?
fluctuates (comes
• vigilant – startled easily to any sound or touch
and goes, changes in
• lethargic – repeatedly dozed off when being asked questions, but
severity)
responded to voice or touch
• stuporous – very difficult to arouse and keep aroused for the
interview
• comatose – could not be aroused
Confusion Assessment Method ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from:
Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
While a Resident
Performed while a resident of this facility and within the last 7
days

1. While a
Resident

At Discharge

2. At Discharge

Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal [PEG])
C. Mechanically altered diet – require change in texture of food or
liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

Section N

Medications

N0420. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the resident is taking any medications in the
following drug classes by pharmacological
classification, not how it is used
2. Indication noted
If Column 1 is checked, check if there is an indication
noted for all medications in the drug class

1. Is taking

2. Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
B. Antianxiety
C. Antidepressant
D. Hypnotic
E. Anticoagulant
F. Antibiotic
G. Diuretic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that
were performed at discharge

At Discharge
Check all that apply

Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that
were performed at discharge

At Discharge
Check all that apply

J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

SNF QRP New and Modified Item Mockups as delineated in the FY 2020 SNF PPS Proposed Rule, Proposed Effective Date:
October 1, 2020