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pdf2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
STATEMENT COST SERIES QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after OMQ.
BOX STBEG
routing
IF ((SP WAS COVERED BY A MEDICARE MANAGED CARE PLAN WITHOUT RX COVERAGE ANYTIME
DURING THE CURRENT ROUND) OR (SP WAS COVERED BY A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND)) AND (SP WAS NOT COVERED BY A MEDICARE PRESCRIPTION DRUG
PLAN ANYTIME DURING THE CURRENT ROUND), GO TO ST1 - MHMOSTMT.
ELSE GO TO ST2 - MCSAVAIL.
Now that we have finished talking about medical visits and prescribed medicines, let’s talk about [your/(SP’s)]
medical costs. We should start by looking at any paperwork or written explanations of what was paid by
Medicare, any insurance company, or TRICARE.
MHMOSTMT
ST1
code one
(01) ALWAYS
[Do you/Does (SP)] usually receive any statements or papers from Medicare, insurance, such as (MANAGED
(02) SOMETIMES
CARE PLAN NAME), or TRICARE that show the charges for medical visits or equipment?/Last time, we recorded
(03) NEVER
that [you/(SP)] (always/sometimes/never) received statements or papers from Medicare, insurance, or TRICARE
(-8) DON'T KNOW
that show the charges for medical visits or equipment.]
(-9) REFUSED
(01) ST2 - MCSAVAIL
(02) ST2 - MCSAVAIL
(03) BOX STEND
(-8) ST2 - MCSAVAIL
(-9) ST2 - MCSAVAIL
Please tell me if (currently) [you always receive statements, sometimes receive statements, or never receive
statements/(SP) always receives statements, sometimes receives statements, or never receives statements].
[Now that we have finished talking about medical visits and prescribed medicines, let’s talk about [your/(SP’s)]
medical costs. We should start by looking at any paperwork or written explanations of what costs were paid by
Medicare, any insurance company, or TRICARE.]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01)
(02)
(-8)
(-9)
ST3 - STHIREP
BOX STEND
BOX STEND
BOX STEND
MCSAVAIL
ST2
yes/no
STHIREP
ST3
no entry
MATCHST
ST4
no entry
[MATCH UP MEDICARE, INSURANCE, TRICARE, AND MEDICARE PRESCRIPTION BENEFIT STATEMENTS
BY PROVIDER AND DATE OF SERVICE./PRESS ENTER TO CONTINUE TO THE NEXT
(STATEMENT/BUNDLE).]
ST5 - ST_CHARGEBUNDLE
ST_CHARGEBUNDLE
ST5
roster
ADD THE SOURCE(S) AND TYPE OF STATEMENT(S) FOR THE (FIRST/NEXT) BUNDLE OF EVENTS.
ADD ONE CHARGE BUNDLE AT THIS ROSTER.
STTYPE (HAD BEEN BOX ST5A)
STTYPE
ST5AA
code one
[PROBE IF NECESSARY: Do you have any statements or paper from Medicare, insurance, or TRICARE [that
[you/(SP)] received since the last interview]? (Please include any statements received about [your/(SP's)]
prescription drug benefit.)]
BASED ON THE INFORMATION RECORDED IN THE HEALTH INSURANCE SECTION FOR RECENT
ROUNDS, THE PLAN(S) LISTED BELOW ARE THE SOURCES OF STATEMENTS YOU MIGHT EXPECT TO
FIND FOR THIS SP.
SELECT SOURCE OF THE STATEMENT(S) FOR THIS CHARGE BUNDLE
ST4 - MATCHST
(01) MEDICARE SUMMARY NOTICE (MSN) ONLY
(02) INSURANCE STATEMENT ONLY
(03) BOTH MEDICARE SUMMARY NOTICE (MSN) AND
INSURNACE STATEMENT
(04) TRICARE STATEMENT ONLY
(05) BOTH MEDICARE SUMMARY NOTICE (MSN) AND
TRICARE STATEMENTS
(06) BOTH TRICARE AND INSURNACE STATEMENTS
(07) MEDICARE SUMMARY NOTICE (MSN) AND TRICARE
AND INSURANCE STATEMENTS
(08) MPDP STATEMENT OR MA/TRICARE PRESCIRPTION
DRUG BUNDLE
(01) ST5AA-MCARTYPE
(02) BOX ST5A
(03) ST5AA-MCARTYPE
(04) BOX ST5A
(05) ST5AA-MCARTYPE
(06) BOX ST5A
(07) ST5AA-MCARTYPE
(08) BOX ST5A
Page 1 of 18
2019 MCBS Community Questionnaire
Variable Name
MCARTYPE
PDPTYPE
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
(01) MEDICARE SUMMARY NOTICE: PART B MEDICAL
INSURANCE - ASSIGNED OR UNASSIGNED (EXAMPLE 1)
(02) MEDICARE SUMMARY NOTICE: PART B MEDICAL
INSURNACE OUTPATIENT FACILITY CLAIMS (EXAMPLE 2)
(03) MEDICARE SUMMARY NOTICE: PART A HOSPITAL
BOX ST5A
INSURANCE INPATIENT CLAIMS (EXAMPLE 3)
(04) MEDICARE SUMMARY NOTICE: HOME HEALTH CARE
CLAIMS (EXAMPLE 4)
(05) MEDICARE SUMMARY NOTICE: PART A HOSPICE
FACILITY CLAIMS (EXAMPLE 5)
ST5AAA
code one
WHICH TYPE OF MEDICARE STATEMENT DO YOU HAVE TO ENTER? [SEE REFERENCE CARDS FOR
MEDICARE STATEMENT EXAMPLES]
BOX ST5A
routing
IF ST5 – STTYPE = 8/MPDPorMAorTricare THEN GO TO ST5A - PDPTYPE.
ELSE GO TO BOX ST5B.
ST5A
code one
SELECT THE TYPE OF PRESCRIPTION DRUG STATEMENT FOR THIS BUNDLE.
BOX ST5B
routing
SET STATEMENT TYPE.
GO TO BOX ST5.
routing
IF TYPE OF STATEMENT = 1/Medicare, 3/MedicareAndInsurance, 5/MedicareAndTricare, OR
7/MedicareAndTricareAndInsurance, GO TO ST7 - MSNCLNUM.
ELSE IF TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance, GO TO ST10 - INSCLNUM.
ELSE IF TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE = 4/Tricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST11B - PDPBEGMM.
BOX ST5
Routing
(01) MEDICARE PRESCRIPTION DRUG BENEFIT
STATEMENT
(02) MEDICARE ADVANTAGE STATEMENT
(03) TRICARE STATEMENT
BOX ST5B
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ST7 - MSNCLNM2
ENTER THE CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN) ASSOCIATED
WITH THE CLAIM TOTAL.
IF NO CLAIM CONTROL NUMBER(S) LISTED, USE F8 TO SELECT 'DON'T KNOW .
MSNCLNUM
ST7
text
DO NOT ENTER ANY CLAIM CONTROL NUMBERS IN COMMENTS.
[INSERT TEXT BOX 1 FOR CLAIM 1]
IF THERE ARE MULTIPLE CLAIM NUMBERS ASSOCIATED WITH THE CLAIM TOTAL, ENTER BELOW:
[INSERT REMAINING TEXT BOXES]
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
MSNCLNM2
ST7
text
MSNCLNM3
ST7
text
MSNCLNM4
ST7
text
MSNCLNM5
ST7
text
BOX ST7
routing
IF ST7 - MSNCLNUM = DK, GO TO BOX ST9.
ELSE GO TO ST8 - MSCLVER1.
ST8
text
PLEASE ENTER THE FIRST CLAIM CONTROL NUMBER FROM THE MEDICARE SUMMARY NOTICE (MSN)
AGAIN.
BOX ST8
routing
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
MSCLVER1
WHICHNUM
ST9
code one
YOU HAVE ENTERED THE CLAIM CONTROL NUMBERS FROM THE MEDICARE SUMMARY NOTICE (MSN)
DIFFERENTLY.
FIRST TIME: (FIRST MSN CLAIM CONTROL NUMBER)
SECOND TIME: (SECOND MSN CLAIM CONTROL NUMBER)
(01) CONTINUOUS ANSWER
ST7 - MSNCLNM3
ST7 - MSNCLNM4
ST7 - MSNCLNM5
BOX ST7
BOX ST8
IF ST8 - MSCLVER1 MATCHES ST7 - MSNCLNUM, GO TO
BOX ST9.
ELSE GO TO ST9 - WHICHNUM.
(01) FIRST
(02) SECOND
(03) NEITHER
(01) BOX ST9
(02) BOX ST9
(03) ST9 - NEWCLNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST9
WHICH IS CORRECT?
NEWCLNUM
ST9
text
ENTER CORRECT MSN CLAIM CONTROL NUMBER:
Page 2 of 18
2019 MCBS Community Questionnaire
Variable Name
Question Type
Question Text/Description
BOX ST9
routing
IF TYPE OF STATEMENT = 3/MedicareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST10 INSCLNUM.
ELSE IF TYPE OF STATEMENT = 5/MedicareAndTricare, GO TO ST11 - TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
ST10
text
ENTER THE CLAIM CONTROL NUMBER FROM THE INSURANCE STATEMENT. IF NO CLAIM CONTROL
NUMBER LISTED, USE F8 TO SELECT 'DON'T KNOW .
BOX ST10
routing
IF TYPE OF STATEMENT = 6/TricareAndInsurance OR 7/MedicareAndTricareAndInsurance, GO TO ST11 TRICLNUM.
ELSE GO TO ST12 - INCTYPE.
TRICLNUM
ST11
text
PDPBEGMM
ST11B
date
PDPBEGDD
ST11B
date
PDPBEGYY
ST11B
date
PDPENDMM
ST11B
date
PDPENDDD
ST11B
date
PDPENDYY
ST11B
date
INCTYPE
ST12
code all
WHAT TYPE(S) OF EVENT(S) ARE INCLUDED IN THIS CHARGE BUNDLE ON THE (TYPE OF STATEMENT)?
CHECK ALL THAT APPLY.
BOX ST12
routing
IF THE RESPONSE TO ST12 - INCTYPE INCLUDES 1/ProvDates, GO TO ST13 - PROVIDER_STDATE.
ELSE GO TO BOX ST26.
INSCLNUM
PROVIDER_STDATE
MR Screen Name
STQ - STATEMENT COST SERIES
ST13
roster
Code List
Routing
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX ST10
ENTER THE CLAIM CONTROL NUMBER FROM THE TRICARE STATEMENT. IF NO CLAIM CONTROL
NUMBER LISTED, ENTER "DON'T KNOW".
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ST12 - INCTYPE
ENTER THE BEGINNING AND ENDING DATES OF SERVICE FROM THE PRESCRIPTION DRUG BENEFIT
STATEMENT.
BEGINNING DATE:
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST11B - PDPBEGDD
ENDING DATE:
WHICH MEDICAL PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) PROVIDER SERVICE DATES
(02) HOME HEALTH VISITS
(03) OTHER MEDICAL EXPENSES
(04) PRESCRIBED MEDICINES
[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.
ST11B - PDPBEGYY
ST11B - PDPENDMM
ST11B - PDPENDDD
ST11B - PDPENDYY
ST12 - INCTYPE
BOX ST12
"IF EXISTING PROVIDER SELECTED,
GO TO ST14 - STDATEUPD.
ELSE IF ""ADD ANOTHER""
SELECTED, GO TO PROV"
[PROVIDER LOOKUP CAN BE CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.
PROVNAME
ST13
verbatim
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
ST13-GROUPNAM
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
NAME:
GROUPNAM
STDATEUPD
ST13
ST14
verbatim
GROUP:
code one
THE FOLLOWING EVENT DATES HAVE BEEN ENTERED FOR THIS PROVIDER.
DO YOU NEED TO ADD OR EDIT AN EVENT DATE FOR THIS CHARGE BUNDLE?
ST14 - STDATEUPD
(01) NO, DO NOT NEED TO ADD OR EDIT EVENT DATES
(02) YES, NEED TO ADD EVENT DATE
(03) YES, NEED TO EDIT EVENT DATE
(01) ST24 - EVENT_STDATE
(02) EVENT DATE ST16 EVENT_STDATEADD
(03) ST15 - EVENT_STDATEDIT
Page 3 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
VISITYPE
VISTYPE
select one
EVENT_STDATEDIT
ST15
roster
Question Text/Description
Code List
Routing
SELECT TYPE OF VISIT TO ADD:
(01) Separately Billing Lab (SL)
(02) Separately Billing Doctor (SD)
(03) Dental (DU)
(08) Vision (VU)
(09) Hearing (HU)
(04) Hospital Emergency Room (ER)
(05) Hospital Inpatient Saty (IP)
(06) Hospital Outpatient Visit (OP)
(07) Institutional Stay (IU)
(10) All other visits to Medical Provider (MP)
ST16 - EVENT
(01) CONTINUOUS ANSWER
ST16-EVENT
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST16A
SELECT AND EDIT THE EVENT DATE THAT NEEDS CORRECTION.
[When did [you/(SP)] see (PROVIDER NAME)?/When [were you/was (SP)] admitted to and discharged from
(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.
EVENT
ST16
roster
ADD THE MISSING EVENT DATE(S) IN THIS CHARGE BUNDLE.
ADD ALL EVENT DATES FOR THIS PROVIDER.
[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.]
STDATEINTRO
BOX ST16A
routing
IF AT LEAST ONE EVENT DATE ADDED AT ST16 IS NOT OUTSIDE THE SURVEY REFERENCE PERIOD, GO
TO BOX ST16B.
ELSE GO TO ST14 - STDATEUPD.
BOX ST16B
routing
IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU' , 'IP', 'OP', OR 'MP' EVENT TYPE, GO TO ST17 STDATEINTRO.
ELSE GO TO BOX ST17.
ST17
no entry
Before we continue with this statement, I would like to ask you a few questions about the visit(s) I just added.
routing
IF AT LEAST ONE EVENT ADDED AT ST16 IS AN 'MP' EVENT TYPE AND THE PROVIDER SPECIALTY HAS
NOT BEEN COLLECTED, GO TO ST18 - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO ST18A - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'VU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO ST18B - PROVSPEC.
ELSE IF AT LEAST ONE EVENT ADDED AT ST16 IS A 'HU' EVENT TYPE AND THE PROVIDER SPECIALTY
HAS NOT BEEN COLLECTED, GO TO ST18C - PROVSPEC.
ELSE GO TO BOX ST18.
BOX ST17
BOX ST17
Page 4 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
What kind of medical person is (PROVIDER NAME)?
PROVSPEC
ST18
code one
PROVSPOS
ST18
text
PROVSPEC
ST18A
code one
[SELECT THE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES
THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT
PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT
LISTED ON SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
Code List
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(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
(42) PHARMACIST
(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
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
Routing
(01)-(34), (42), (-8), (-9) BOX ST18
(91) ST18 - PROVSPOS
OTHER MEDICAL PROVIDER (SPECIFY)
(01) CONTINUOUS ANSWER
BOX ST18
What kind of dental provider is [PROVNAME]?
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST18
(35) BOX ST18
(36) BOX ST18
(37) BOX ST18
(38) BOX ST18
(39) BOX ST18
(40) BOX ST18
(41) BOX ST18
(91) ST18A - PROVSPOS
(-8) BOX ST18
(-9) BOX ST18
Page 5 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
(01)-(34), (-8), (-9) BOX ST18
(91) ST18A - PROVSPOS
PROVSPEC
ST18A1
code one
What kind of dental provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(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
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
PROVPOS
ST18A
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX ST18
What kind of eye care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX ST18
(16) BOX ST18
(43) BOX ST18
(91) ST18B- PROVSPECOTH
(-8) BOX ST18
(-9) BOX ST18
PROVSPEC
PROVSPEC
ST18B
ST18B1
code one
code one
What kind of eye care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(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) (DO NOT DISPLAY)
(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
(30) HOMEOPATH
(01)-(34), (-8), (-9) BOX ST18
(91) ST18B - PROVSPOS
Page 6 of 18
2019 MCBS Community Questionnaire
STQ - STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
Routing
PROVPOS
ST18B
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX ST18
What kind of hearing care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
(02) BOX ST18
(03) BOX ST18
(44) BOX ST18
(45) BOX ST18
(91) ST18C- PROVSPECOTH
(-8) BOX ST18
(-9) BOX ST18
(01)-(34), (-8), (-9) BOX ST18
(91) ST18C - PROVSPOS
PROVSPEC
ST18C
code one
PROVSPEC
ST18C1
code one
What kind of hearing care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(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
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
PROVPOS
ST18C
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX ST18
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST19
BOX ST18
routing
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', 'IU', OR 'MP' EVENT TYPE)
AND (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 ST19 VAPLACE.
ELSE GO TO BOX ST19.
VAPLACE
ST19
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A. facility?
Page 7 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
BOX ST19
HMOASSOC
HMOREFER
ST20
ST21
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
routing
IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU'', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE) AND
(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 ST20 - HMOASSOC.
ELSE IF (AT LEAST ONE EVENT ADDED AT ST16 IS A 'DU', 'VU', 'HU', 'ER', 'IP', 'OP', OR 'MP' EVENT TYPE)
AND (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 ST21 - HMOREFER.
ELSE GO TO BOX ST22A.
yes/no
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
BOX ST22A
routing
FOR THIS EVENT ADDED AT ST16,
IF TYPE OF EVENT = 'IP', GO TO IP7 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'OP', GO TO OP5 - ANYOPERS.
ELSE IF TYPE OF EVENT = 'MP', GO TO BOX ST22B.
ELSE IF TYPE OF EVENT = 'DU', GO TO DU7 - DVPROCDR.
ELSE IF TYPE OF EVENT = 'VU', GO TO VU7 - VUPROCDR.
ELSE IF TYPE OF EVENT = 'HU', GO TO HU7 - HUPROCDR.
ELSE GO TO BOX ST23B.
BOX ST22B
routing
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 ST23 - MPSDVIS.
ELSE GO TO BOX ST23A.
ST23
yes/no
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in [READ EVENT(S) LISTED BELOW].
Was this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED
BELOW]/any of these places]?
BOX ST23A
routing
BOX ST23B
routing
ST24
roster
BOX ST24
routing
ST24A
numeric
ENTER THE NUMBER OF (EVENT TYPE) VISITS IN (EVENT MONTH, YEAR) THAT ARE COVERED BY THIS
CHARGE.
BOX ST24A
routing
IF ANOTHER EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
STDATEMTCH
ST25
code one
ARE ALL THE PROVIDER EVENTS FROM THE CHARGE BUNDLE ON (TYPE OF STATEMENT) SHOWN
BELOW?
EVENT_STDATEDEL
ST26
roster
BOX ST26
routing
PROVIDER_STHH
ST27
roster
COSTBEGM
ST28
numeric
COSTBEGD
ST28
numeric
COSTBEGY
ST28
numeric
COSTENDM
ST28
numeric
COSTENDD
ST28
numeric
MPSDVIS
EVENT_STDATE
RVLINKS
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST22A
(02) ST21 - HMOREFER
(-8) ST21 - HMOREFER
(-9) ST21 - HMOREFER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST22A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST23A
(01) CONTINUOUS ANSWER
BOX ST24
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST24A
(01) YES
(02) NO, NEED TO ADD A PROVIDER EVENT
(03) NO, NEED TO REMOVE A PROVIDER EVENT
(01) CONTINUOUS ANSWER
(01) BOX ST26
(02) ST13 - PROVIDER_STDATE
(03) ST26 - EVENT_STDATEDEL
ST25 - STDATEMTCH
(01) CONTINUOUS ANSWER
ST28 - COSTBEGM
IF ST23 ASKED AND ST23 - MPSDVIS = 1/Yes, GO TO BOX ST23B.
ELSE GO TO BOX MP2C.
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER AT ST16, GO TO BOX ST22A.
ELSE GO TO ST24-EVENT_STDATE.
SELECT THE EVENT DATE(S) THAT ARE INCLUDED IN THIS CHARGE BUNDLE.
IF AT LEAST ONE EVENT SELECTED AT ST24 IS A REPEAT VISIT, GO TO ST24A - RVLINKS.
ELSE GO TO ST25 - STDATEMTCH.
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
IF ST12 – INCTYPE INCLUDES 2/HHVisits, GO TO ST27 - PROVIDER_STHH.
ELSE GO TO BOX ST33.
WHICH HOME HEALTH PROVIDER IS IN THIS CHARGE BUNDLE?
SELECT OR ADD ONLY ONE PROVIDER.
ENTER THE START DATE AND STOP DATE COVERED BY THE CHARGE BUNDLE.
START DATE:
STOP DATE:
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST28 - COSTBEGD
ST28 - COSTBEGY
ST28 - COSTENDM
ST28 - COSTENDD
ST28 - COSTENDY
Page 8 of 18
2019 MCBS Community Questionnaire
STQ - STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
COSTENDY
ST28
numeric
BOX ST28A
routing
IF (HOME HEALTH PROVIDER WAS ADDED AT ST27) OR (AN EXISTING PROVIDER WAS SELECTED AT
ST27 THAT WAS NOT ASSOCIATED WITH A HOME HEALTH EVENT), GO TO ST30 - HHEVNTTYPE.
ELSE GO TO BOX ST31B.
HHEVNTTYPE
ST30
code one
IS THE PROVIDER A HOME HEALTH PROFESSIONAL OR SOME OTHER TYPE OF HOME HEALTH
PROVIDER (HOME HEALTH AIDE, HOMEMAKER, ETC.)?
(01) HOME HEALTH PROFESSIONAL
(02) OTHER HOME HEALTH PROVIDER
STHHINTRO
ST31
no entry
Before we continue with this statement, I would like to ask you a few questions about the home health provider I
just added.
BOX ST31A
BOX ST31A
routing
IF ST30 - HHEVNTTYPE = 1/HP, GO TO HH3 - PROVSPEC.
ELSE GO TO HH20 - HHFTYPE.
BOX ST31B
routing
LINK HOME HEALTH PROVIDER TO CHARGE BUNDLE
GO TO ST32 - STHHMTCH.
ST32
code one
BOX ST33
routing
STOMUPD
ST34
code one
EVENT_STOMEDIT
ST35
roster
STHHMTCH
STOMADD
DO YOU NEED TO ADD OR EDIT AN OME EVENT FOR THIS CHARGE BUNDLE?
routing
ST37
roster
GO TO ST34 - STOMUPD.
SELECT OTHER MEDICAL EXPENSES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF
STATEMENT).
BOX ST37
routing
ST38
BOX ST28A
ST31 - STHHINTRO
BOX ST33
(01) NO, DO NOT NEED TO ADD OR EDIT OM EVENT
(02) YES, NEED TO ADD AN OME EVENT
(03) YES, NEED TO EDIT AN OME EVENT
(01) ST37 - EVENT_STOM
(02) ST36 - STOMADD
(03) ST35 - EVENT_STOMEDIT
(01) GLASSES/CONTACTS
(11) HEARING AID
(02) HEARING/SPEECH DEVICE
(03) ORTHOPEDIC ITEM
(04) DIABETIC SUPPLIES
(05) AMBULANCE/RESCUE
(06 PROSTHESIS
(07) ALTERATIONS (HOME/CAR)
(08) OXYGEN
(09) KIDNEY DIALYSIS
(10) ALL OTHER MEDICAL SUPPLIES
(01) OM1B-VUTYPE
(11) OM3B-INLEFT
(02) OM33-EVENT_OMHRSP
(03) OM6 - ORTHTYPE
(04) OM10 - EVENT_OMDIAB
(05) OM12 - EVENT_OMAMBL
(06) OM14 - EVENT_OMPROS
(07) OM29 - ALTRTYPE
(08) OM19A - OXGNTYPE
(09) OM21A - KDNYTYPE
(10) OM24 - OTHRTYPE
SELECT AND EDIT THE OTHER MEDICAL EXPENSE EVENT THAT NEEDS CORRECTION.
BOX ST36
MONCOV96
STOMMTCH
THE FOLLOWING OME EVENTS HAVE BEEN ENTERED.
WHAT TYPE OF OTHER MEDICAL EXPENSE NEEDS TO BE ADDED?
numeric
Routing
IF ST12 – INCTYPE INCLUDES 3/OMExpenses, GO TO ST34 - STOMUPD.
ELSE GO TO BOX ST40.
code one
ST38
Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
THE FOLLOWING HOME HEALTH PROVIDER EVENT HAS BEEN ADDED TO THIS CHARGE BUNDLE.
ST36
MONTHCOV
NUMLINKS
Question Text/Description
BOX ST37
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
HOW MANY MONTHS ARE COVERED BY THIS CHARGE BUNDLE?
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
(01) LESS THAN 1 MONTH
(-7) EMPTY
BOX ST38A
routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS RENTED, GO TO ST38 - MONTHCOV.
ELSE GO TO BOX ST38B.
BOX ST38B
routing
IF AT LEAST ONE OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
ST38A
numeric
HOW MANY PURCHASES OF (NAME OF OME ITEM) ARE COVERED BY THIS CHARGE BUNDLE?
BOX ST38AA
routing
IF ANOTHER OTHER MEDICAL EXPENSE SELECTED AT ST37 IS OSTOMY SUPPLIES, INCONTINENCE
SUPPLIES OR BANDAGES, GO TO ST38A - NUMLINKS.
ELSE GO TO ST39 - STOMMTCH.
ST39
code one
(01) YES
ARE ALL THE OTHER MEDICAL EXPENSES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
(02) NO, NEED TO ADD AN OME EVENT
SHOWN BELOW?
(03) NO, NEED TO REMOVE AN OME EVENT
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST38 - MONCOV96
BOX ST38A
BOX ST38AA
(01) BOX ST40
(02) ST34 - STOMUPD
(03) ST40 - EVENT_STOMDEL
Page 9 of 18
2019 MCBS Community Questionnaire
STQ - STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
EVENT_STOMDEL
ST40
roster
SELECT THE EVENT(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE BUNDLE.
(01) CONTINUOUS ANSWER
BOX ST40
routing
IF ST12 – INCTYPE INCLUDES 4/PMS, GO TO ST41 - EVENT_STPM.
ELSE GO TO BOX ST45.
ST41
roster
SELECT OR ADD ALL PRESCRIPTION MEDICINES THAT ARE IN THIS CHARGE BUNDLE ON THE (TYPE OF
(01) CONTINUOUS ANSWER
STATEMENT).
BOX PM2
routing
EVENT_STPM
MEDICINE_PM1
Routing
BOX PM2
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
(01) YES
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
(02) NO
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
(03) NO BUT R CAN ANSWER QUESTIONS
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT
(-8) DON'T KNOW
THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(-9) REFUSED
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Page 10 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
Code List
Routing
Medicine Form [MCBS FORM]
(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS, DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
Medicine strength unit
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-MEDID
(-9) MED-MEDID
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) BOX PM5
(20) PMCOND-PMCONDOS
(-8) BOX PM5
(-9) BOX PM5
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX PM5
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
Page 11 of 18
2019 MCBS Community Questionnaire
Variable Name
TABNUM
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
BOX PM5
routing
IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
TABNUM
numeric
AMTUNIT
PM16
quantity unit
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
BOX PM6
routing
Code List
Routing
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
BOX PM6
OTHER (SPECIFY)
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PMSATVA
PMSATHMO
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
PMSATHMO
yes/no
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)] (-9) REFUSED
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-PMMORE
Page 12 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
Code List
Routing
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) ST42 - NUMLINKS
PMMORE
PMMORE
yes/no
NUMLINKS
ST42
grid
HOW MANY PURCHASES OF EACH MEDICINE SHOWN BELOW ARE COVERED BY THIS CHARGE
BUNDLE?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST44-STPMMTCH
STPMMTCH
ST44
code one
ARE ALL THE PRESCRIBED MEDICINES FROM THE CHARGE BUNDLE ON THE (TYPE OF STATEMENT)
SHOWN BELOW?
(01) YES
(02) NO, NEED TO ADD A MEDICINE NAME
(03) NO, NEED TO REMOVE A MEDICINE NAME
(01) BOX ST45
(02) ST41 - EVENT_STPM
(03) ST45 - EVENT_STPMDEL
EVENT_STPMDEL
ST45
roster
(01) CONTINUOUS ANSWER
ST44 - STPMMTCH
BOX ST45
routing
ST46
no entry
SINCE ALL EVENTS IN THIS BUNDLE ARE OUTSIDE THE SURVEY REFERENCE PERIOD, WE DO NOT
NEED ANY CHARGE INFORMATION ABOUT THE BUNDLE.
BOX ST46
routing
IF (TYPE OF STATEMENT = 2/Insurance OR 6/TricareAndInsurance) OR (TYPE OF STATEMENT = 4/Tricare
AND ST5 – STTTYPE = 4/Tricare) OR (ST5 - MCARTYPE = 4/MSNPartB), GO TO ST47 - ASGNTAKE.
ELSE GO TO BOX ST47.
ST47
code one
WAS ASSIGNMENT TAKEN FOR THIS CHARGE BUNDLE?
BOX ST47
routing
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)), GO TO ST47A - TOTALCHG.
ELSE IF (TYPE OF STATEMENT = 2/Insurance) OR (TYPE OF STATEMENT = 4/Tricare AND ST5 - STTYPE =
4/Tricare) OR (TYPE OF STATEMENT = 6/TricareAndInsurance), GO TO ST48 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 4/MSNPartB, GO TO ST52 - TOTALCHG.
ELSE IF ST5 - MCARTYPE = 6/MSNPartAInpatient, GO TO ST56 - DAYSUSED.
ELSE GO TO ST60 - TOTALCHG.
TOTALCHG
ST47A
dollar
TOTALCHG
ST48
numeric
MCAPPAMT
ST48
numeric
MCPAYAMT
ST48
numeric
BOX ST48
routing
ORPMESSAGE
ASGNTAKE
STTCHGPAID1
ST49
code one
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]
SELECT THE PRESCRIBED MEDICINE(S) THAT YOU WOULD LIKE TO REMOVE FROM THE CHARGE
BUNDLE.
IF ALL EVENT DATES SELECTED FOR THIS CHARGE BUNDLE ARE OUTSIDE THE SURVEY REFERENCE
PERIOD, GO TO ST46 - ORPMESSAGE.
ELSE GO TO BOX ST46.
BOX ST80
(01) YES
(02) NO
(03) CAN'T TELL
ENTER THE TOTAL COST OF PRESCRIPTION(S) FROM THE PRESCRIPTION DRUG BENEFIT STATEMENT. (01) CONTINUOUS ANSWER
IF A TOTAL COST IS NOT LISTED, IT MAY BE NECESSARY TO CALCULATE A TOTAL BY ADDING THE
(-8) DON'T KNOW
COSTS OF INDIVIDUAL ITEMS LISTED ON THE STATEMENT.
(-9) REFUSED
(01) CONTINUOUS ANSWER
ENTER THE FOLLOWING AMOUNTS FROM THE (TYPE OF STATEMENT). IF AMOUNT NOT AVAILABLE,
(-8) DON'T KNOW
ENTER "DON'T KNOW".
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST51.
ELSE IF (AMOUNT REMAINING < $1.00) OR ((ST48 - MCAPPAMT ^= DK OR RF) AND (AMOUNT REMAINING
< .02 * ST48 - MCAPPAMT)), GO TO BOX ST80.
ELSE GO TO ST49 - STTCHGPAID1.
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
BOX ST47
ST64 - STTCHGPAID2
ST48 - MCAPPAMT
ST48 - MCPAYAMT
BOX ST48
(01) BOX ST64A
(02) BOX ST64A
(03) ST50 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) STATEMENT:
TOTAL CHARGE/BILLED AMOUNT: (TOTAL CHARGE AMOUNT)
CHANGAMT
ST50
yes/no
TOTAL MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
TOTAL MEDICARE PAYMENT: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST51 - TOTALCHG
(02) BOX ST51
AMOUNT REMAINING AFTER MEDICARE PAYMENT: (AMOUNT REMAINING)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST51
numeric
MCAPPAMT
ST51
numeric
MCPAYAMT
ST51
numeric
(01) CONTINUOUS ANSWER
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE
(-8) DON'T KNOW
OF STATEMENT).
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST51 - MCAPPAMT
ST51 - MCPAYAMT
BOX ST51
Page 13 of 18
2019 MCBS Community Questionnaire
Variable Name
STQ - STATEMENT COST SERIES
MR Screen Name
Question Type
BOX ST51
routing
TOTALCHG
ST52
numeric
MCAPPAMT
ST52
numeric
MCPAYAMT
ST52
numeric
MAYBBILL
ST52
numeric
BOX ST52
routing
STTCHGPAID1
ST53
code one
Question Text/Description
Code List
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND ((AMOUNT REMAINING < $1.00)
OR ((ST51 - MCAPPAMT ^= DK AND ST51 - MCAPPAMT ^= RF) AND (AMOUNT REMAINING < .02 * ST51 MCAPPAMT))), GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
ENTER THE FOLLOWING AMOUNTS FROM THE MSN:
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST55.
ELSE IF (AMOUNT REMAINING < $1.00), GO TO BOX ST80.
ELSE GO TO ST53 - STTCHGPAID1.
Routing
REVIEW CHARGE BUNDLE ON THE (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T
ALREADY DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining of $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or
any other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this
amount?
(01) BOX ST64A
(02) BOX ST64A
(03) ST54 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
ST52 - MCAPPAMT
ST52 - MCPAYAMT
ST52 - MAYBBILL
BOX ST52
THESE AMOUNTS WERE ENTERED FROM THE (TYPE OF STATEMENT) :
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
CHANGAMT
ST54
yes/no
MEDICARE APPROVED: (MEDICARE APPROVED AMOUNT)
MEDICARE PAID: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST55 - TOTALCHG
(02) BOX ST55
YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST55
numeric
MCAPPAMT
ST55
numeric
MCPAYAMT
ST55
numeric
MAYBBILL
ST55
numeric
BOX ST55
routing
DAYSUSED
ST56
numeric
NONCOVRD
ST56
numeric
MCPAYAMT
ST56
numeric
MAYBBILL
ST56
numeric
BOX ST56
routing
STTCHGPAID1
ST57
code one
(01) CONTINUOUS ANSWER
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE
(-8) DON'T KNOW
OF STATEMENT).
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(01) CONTINUOUS ANSWER
DISREGARD "AMOUNT CHARGED" IF IT APPEARS ON THE STATEMENT.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST59.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST57 - STTCHGPAID1.
(01) SP OR ANY SOURCE PAID
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
(02) NOTHING HAS BEEN PAID
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
(03) AMOUNT REMAINING SEEMS WRONG
So, I have an amount remaining $(AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any
(-8) DON'T KNOW
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount?
(-9) REFUSED
ST55 - MCAPPAMT
ST55 - MCPAYAMT
ST55 - MAYBBILL
BOX ST55
ST56 - NONCOVRD
ST56 - MCPAYAMT
ST56 - MAYBBILL
BOX ST56
(01) BOX ST64A
(02) BOX ST64A
(03) ST58 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
THESE AMOUNTS WERE ENTERED FROM THE MSN:
BENEFITS DAYS USED: (DAYS USED)
CHANGAMT
ST58
yes/no
NON-COVERED CHARGES: (NON COVERED CHARGES)
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)
(01) YES
(02) NO
(01) ST59 - DAYSUSED
(02) BOX ST59
MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
DAYSUSED
ST59
numeric
NONCOVRD
ST59
numeric
MCPAYAMT
ST59
numeric
MAKE ALL THE NECESSARY CORRECTIONS TO THE AMOUNTS THAT WERE ENTERED FROM THE (TYPE
(01) CONTINUOUS ANSWER
OF STATEMENT).
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST59 - MCPAYAMT
ST59 - MAYBBILL
Page 14 of 18
2019 MCBS Community Questionnaire
STQ - STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
MAYBBILL
ST59
numeric
BOX ST59
routing
TOTALCHG
ST60
numeric
MCAPPAMT
ST60
numeric
MCPAYAMT
ST60
numeric
MAYBBILL
ST60
numeric
STTCHGPAID1
Question Text/Description
Code List
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00), (01) CONTINUOUS ANSWER
GO TO BOX ST80.
(-8) DON'T KNOW
ELSE GO TO ST64 - STTCHGPAID2.
(-9) REFUSED
(01) CONTINUOUS ANSWER
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST60
IF AMOUNT REMAINING = DK OR EMPTY, GO TO BOX ST63.
ELSE IF AMOUNT REMAINING < $1.00, GO TO BOX ST80.
ELSE GO TO ST61 - STTCHGPAID1.
ST61
REVIEW CHARGE BUNDLE ON (TYPE OF STATEMENT) WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT PROVIDER NAME, DATE(S), AND TYPE OF SERVICE. THEN ASK:
So, I have an amount remaining (AMOUNT REMAINING) that Medicare didn't pay. [Have you/Has (SP)] or any
other source, [such as (TRICARE/an insurance plan/TRICARE or an insurance plan)], paid any of this amount?
code one
Routing
BOX ST59
ST60 - NONCOVRD
ST60 -MCAPPAMT
ST60 - MCPAYAMT
ST60 - MAYBBILL
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
BOX ST60
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(03) AMOUNT REMAINING SEEMS WRONG
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX ST64A
(02) BOX ST64A
(03) ST62 - CHANGAMT
(-8) BOX ST64A
(-9) BOX ST64A
(01) YES
(02) NO
(01) ST63 - TOTALCHG
(02) BOX ST63
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63- MCAPPAMT
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
ST63 - MCPAYAMT
THESE AMOUNTS WERE ENTERED FROM THE MSN:
AMOUNT CHARGED: (TOTAL CHARGE AMOUNT)
CHANGAMT
ST62
yes/no
MEDICARE APPROVED AMOUNT: (MEDICARE APPROVED AMOUNT)
AMOUNT MEDICARE PAID: (MEDICARE PAYMENT)
MAXIMUM YOU MAY BE BILLED: (MAY BE BILLED)
DO YOU WANT TO MAKE ANY CHANGES?
TOTALCHG
ST63
numeric
MCAPPAMT
ST63
numeric
MCPAYAMT
ST63
numeric
MAYBBILL
ST63
numeric
BOX ST63
STTCHGPAID2
ST64
BOX ST64A
BOX ST64B
STADDSOP1
ST65
ENTER THE FOLLOWING AMOUNTS FROM THE MSN.
routing
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AMOUNT REMAINING < $1.00),
GO TO BOX ST80.
ELSE GO TO ST64 - STTCHGPAID2.
code one
REVIEW CHARGE BUNDLE ON [TYPE OF STATEMENT] WITH RESPONDENT IF YOU HAVEN'T ALREADY
DONE SO. POINT OUT (PROVIDER NAME), DATE(S), AND TYPE OF SERVICE(S). (THEN ASK:/SELECT "SP
OR ANY SOURCE PAID" IF ALREADY KNOWN. OTHERWISE ASK:)
[The total cost of prescriptions reported on this statement is (TOTAL CHARGE TEXT).] [[Have you/Has
(SP)]/Besides Medicare, [have you/has (SP)]] or any other source [, such as (an insurance
plan/TRICARE/TRICARE or an insurance plan),] paid anything for this?
routing
IF SP OR ANY SOURCE HAS PAID, GO TO BOX ST64B.
ELSE IF (NOTHING HAS BEEN PAID) OR (RESPONDENT DOES NOT KNOW IF ANYTHING HAS BEEN PAID),
GO TO BOX ST78B.
ELSE GO TO BOX ST80.
routing
CREATE SOURCE OF PAYMENT ROSTER
IF ADMINISTERING ST AND (ONE OR MORE CHARGE BUNDLES ENTERED IN ST SECTION) AND (ST65 –
STADDSOP1 HAS BEEN ASKED IN THE CURRENT ROUND) AND (PAYMENTS HAVE BEEN COLLECTED AT
ST67), GO TO ST67 - TSOPAMT.
yes/no
ARE ALL OF THE SOURCES OF PAYMENT NECESSARY FOR COMPLETING THE STATEMENT SECTION
LISTED BELOW?
SELECT "NO" TO ADD A SOURCE OF PAYMENT.
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) SP OR ANY SOURCE PAID
(02) NOTHING HAS BEEN PAID
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
ST63 - MAYBBILL
BOX ST63
BOX ST64A
(01) ST67 - TSOPAMT
(02) ST66 - SOP_ST1
Page 15 of 18
2019 MCBS Community Questionnaire
STQ - STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
Question Text/Description
SOP_ST1
ST66
roster
ADD ALL ADDITIONAL SOURCES OF PAYMENT.
TSOPAMT
PAYMHE
PLANINTRO
ST67
grid
BOX ST67HE
routing
ST67HE
no entry
STSOPCURR1
STMPDPCHNG
IF AT LEAST ONE TSOPAMT = DK OR RF OR THE SUM OF ALL TSOPAMT
VALUES FOR THIS COST > 0.00, GO TO BOX ST67A.
ELSE GO TO ST67HE - PAYMHE.
THE SUM OF ALL PAYMENT AMOUNTS MUST BE GREATER THAN $0.00 OR AT LEAST ONE PAYMENT
AMOUNT MUST BE 'DON'T KNOW' OR 'REFUSED'.
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(-9) REFUSED
BOX ST67HE
(01) CONTINUOUS ANSWER
ST67HE-PAYMHE
(01) CONTINUOUS ANSWER
BOX ST67C
USE "PREVIOUS PAGE" TO RETURN TO THE SOP GRID AND MAKE CORRECTIONS.
IF AT LEAST ONE SOURCE OF PAYMENT WAS ADDED AT ST66, GO TO BOX ST67B.
ELSE GO TO BOX ST69F.
IF AT LEAST ONE SOURCE OF PAYMENT ADDED AT ST66 IS A HEALTH INSURANCE PLAN, GO TO
ST67BINT - PLANINTRO. ELSE GO TO BOX ST69E.
routing
BOX ST67B
routing
ST67BINT
no entry
Before we continue, I would like to ask you a few questions about the health insurance plan(s) you just added.
routing
CREATE A NEW HEALTH INSURANCE PLAN FOR FIRST/NEXT SOURCE OF PAYMENT ADDED AT ST66
IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP HAS A MEDICARE MANAGED
CARE PLAN THAT IS CURRENT, GO TO ST68 - STMHMOCHNG1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE MANAGED CARE PLAN AND SP DOES NOT HAVE A
MEDICARE MANAGED CARE PLAN THAT IS CURRENT, GO TO ST69 - STSOPCURR1.
ELSE IF SOURCE OF PAYMENT IS A MEDICARE PRESCRIPTION DRUG PLAN AND SP HAS A MEDICARE
PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO ST69A - STMPDPCHNG.
ELSE IF SOURCE OF PAYMENT IS MEDICARE PRESCRIPTION DRUG PLAN AND SP DOES NOT HAVE A
MEDICARE PRESCRIPTION DRUG PLAN THAT IS CURRENT, GO TO ST69B - STSOPCURR2.
ELSE IF SOURCE OF PAYMENT IS MEDICAID, GO TO HI6 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PUBLIC PLAN, GO TO HI13 - COVTIME.
ELSE IF SOURCE OF PAYMENT IS A PRIVATE PLAN, GO TO HI21 - COVTIME.
ELSE GO TO HIT2 - COVTIME.
yes/no
I recorded previously that (CURRENT MEDICARE MANAGED CARE PLAN NAME) was [your/(SP's)] current
Medicare Managed Care Plan. Has this information changed?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ST69 - STSOPCURR1
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE MANAGED CARE PLAN
NAME) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) HIMC6A - MHMORXTM
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) ST69B - STSOPCURR2
(02) BOX ST69A
(-8) BOX ST69A
(-9) BOX ST69A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST69A
ST68
ST69
ST69A
yes/no
I recorded previously that (CURRENT MEDICARE PRESCRIPTION DRUG PLAN) was [your/(SP's)] current
Medicare Prescription Drug Care Plan.
Has this information changed?
STSOPCURR2
Routing
BOXST67A
BOX ST67C
STMHMOCHNG1
(REFER TO INSURANCE STATEMENT/REFER TO TRICARE STATEMENT/REFER TO INSURANCE AND
TRICARE STATEMENTS/REFER TO MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT).
Who (else) paid besides Medicare? How much did (SOURCE) pay?
ENTER ALL PAYMENT AMOUNTS. CORRECT PAYMENT AMOUNTS AS NECESSARY.
Code List
(01) CONTINUOUS ANSWER
ST69B
yes/no
[Are you/Is (SP)/Was (SP)] [currently] covered or enrolled in (ST66 SOP MEDICARE PRESCRIPTION DRUG
PLAN) [on (DATE OF DEATH/DATE OF INSTITUTIONALIZATION)]?
BOX ST69A
routing
IF ANOTHER SOP WAS ADDED AT ST66, GO TO BOX ST67C.
ELSE GO TO BOX ST69E.
BOX ST69E
routing
IF AN "OTHER SOURCE OF PAYMENT" ADDED AT ST66, CREATE AN OSOP FOR EACH SOURCE OF
PAYMENT ADDED AT ST66 THAT IS AN "OTHER SOURCE OF PAYMENT"
GO TO BOX ST69F.
Page 16 of 18
2019 MCBS Community Questionnaire
Variable Name
MR Screen Name
BOX ST69F
AMTSCORR
AMTSCORR
ST70
ST71
STQ - STATEMENT COST SERIES
Question Type
Question Text/Description
routing
IF ((TYPE OF STATEMENT = 8/MPDPBenefit) or (TYPE OF STATEMENT = 4/Tricare and ST5 - STTYPE =
8/MPDPorMAorTricare)) and ((TOTAL CHARGE ^= DK and TOTAL CHARGE ^= RF) and (ALL PAYMENTS
ENTERED AT ST67 ^= DK AND ^= RF)) AND ((TOTAL CHARGE IS > TOTAL PAYMENTS ENTERED AT ST67)
AND (THE DIFFERENCE BETWEEN TOTAL CHARGE AND TOTAL PAYMENTS ENTERED AT ST67 IS >
$1.00)), GO TO ST73 - AMTSCORR.
IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (AT LEAST ONE PAYMENT
ENTERED AT ST67 = DK OR RF) AND (AT LEAST ONE PAYMENT ENTERED AT ST67 ^= DK AND ^= RF) AND
(TOTAL OF ALL NON-MISSING PAYMENTS ENTERED AT ST67 IS >= AMOUNT REMAINING), GO TO ST71 AMTSCORR.
ELSE IF (AMOUNT REMAINING ^= DK AND AMOUNT REMAINING ^= EMPTY) AND (ALL PAYMENTS
ENTERED AT ST67 ^= DK AND ^= RF) AND (THE ABSOLUTE VALUE OF THE DIFFERENCE BETWEEN THE
TOTAL PAYMENTS ENTERED AT ST67 AND AMOUNT REMAINING IS > $1.00), GO TO ST70 - AMTSCORR.
ELSE GO TO BOX ST77C.
code one
There seems to be (some amount still unpaid/more payments than the amount left after Medicare paid). The
total of non-Medicare payments is $(TOTAL PAYMENTS). The amount (unpaid/overpaid) is $(DIFFERENCE
BETWEEN PAYMENTS AND AMOUNT REMAINING). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO
THE SOP GRID.
code one
THE AMOUNTS ENTERED FOR THE SOURCES OF PAYMENT EQUAL OR EXCEED THE (TOTAL
CHARGE/AMOUNT REMAINING), WITH AT LEAST ONE SOP BEING A MISSING AMOUNT. VERIFY ALL
AMOUNTS AS ENTERED.
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO
THE SOP GRID.
ENTERCOM
ST72
no entry
[THE TOTAL OF NON-MEDICARE PAYMENTS IS $(TOTAL PAYMENTS). THE AMOUNT (UNPAID/OVERPAID)
IS $(DIFFERENCE BETWEEN PAYMENTS AND AMOUNT REMAINING).]
USE COMMENTS TO EXPLAIN WHY THE AMOUNT REMAINING SEEMS INCORRECT.
Code List
Routing
(01) ENTRIES ABOVE ARE CORRECT
(02) DO NOT DISPLAY
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED
(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT
(-8)
(-9) REFUSED
(01) BOX ST77C
(02) DO NOT DISPLAY.
(03) ST72 - ENTERCOM
(-8) BOX ST77C
(-9) BOX ST77C
(01) CONTINUOUS ANSWER
BOX ST77C
(01) ENTRIES ABOVE ARE CORRECT
(02) NO, SOP NEEDS ADDITION OR CORRECTION DO NOT
DISPLAY.
(03) AMOUNT REMAINING SEEMS INCORRECT DO NOT
DISPLAY.
(-8)
(-9) REFUSED
(01) ST74 - INFOEXPLAIN
(02) DO NOT DISPLAY.
(03) DO NOT DISPLAY.
(-8) BOX ST77C
(-9) BOX ST77C
(01) ST75 - ENTERCOM2
(02) BOX ST77C
AMTSCORR
ST73
yes/no
There seems to be some amount still unpaid. The total of non-Medicare payments is $(TOTAL PAYMENTS).
The amount unpaid is $(DIFFERENCE BETWEEN TOTAL CHARGE AND PAYMENTS). Is that correct?
IF SOURCE OF PAYMENT NEEDS ADDITION OR CORRECTION, USE "PREVIOUS PAGE" TO RETURN TO
THE SOP GRID.
INFOEXPLAIN
ST74
yes/no
IS THERE ADDITIONAL INFORMATION ON THE DRUG BENEFIT STATEMENT THAT EXPLAINS THE
AMOUNT STILL UNPAID?
(01) YES
(02) NO
ENTERCOM2
ST75
verbatim text
USE THE BOX BELOW TO ENTER ANY INFORMATION THAT EXPLAINS THE AMOUNT STILL UNPAID.
(01) CONTINUOUS ANSWER
BOX ST77C
routing
CREATE PAYMENTS FOR AMOUNTS ENTERED AT ST67
GO TO BOX ST77D.
BOX ST77D
routing
IF THE SP OR FAMILY MADE A PAYMENT AND PAYMENT IS GREATER THAN $5.00, GO TO ST78 EXPPAYBK.
ELSE GO TO BOX ST80.
ST78
yes/no
I have recorded that [you have/(SP) has] paid $(SP/FAMILY PAYMENT). Do you expect any source to pay
[you/(SP)] back any or all of that amount?
BOX ST78A
routing
IF ST78 - EXPPAYBK = 1/Yes AND ((CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST
COLLECTED 2 ROUNDS PREVIOUS TO CURRENT ROUND) , GO TO ST80 - EXPAYUNT.
ELSE GO TO BOX ST80.
BOX ST78B
routing
IF (CURRENTLY ADMINISTERING CPS AND CHARGES WERE FIRST COLLECTED 2 ROUNDS PREVIOUS
TO CURRENT ROUND), GO TO ST79 - EXPAYOUT.
ELSE GO TO BOX ST80.
EXPPAYBK
EXPAYOUT
ST79
yes/no
Do you expect anyone to pay any of this amount?
EXPAYUNT
ST80
quantity unit
How much do you expect will be paid?
EXPAYPCT
ST80
numeric
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX ST78A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) PERCENTAGE
(02) DOLLARS
(-8) DON'T KNOW
(-9) REFUSED
(01) ST80 - EXPAYUNT
(02) BOX ST80
(-8) BOX ST80
(-9) BOX ST80
(01) ST80 - EXPAYPCT
(02) ST80 - EXPAYAMT
(-8) BOX ST80
(-9) BOX ST80
(01) CONTINUOUS ANSWER
BOX ST80
Page 17 of 18
2019 MCBS Community Questionnaire
STQ - STATEMENT COST SERIES
Variable Name
MR Screen Name
Question Type
EXPAYAMT
ST80
numeric
BOX ST80
routing
IF CURRENTLY ADMINISTERING NS, GO TO BOX NSBEG.
ELSE IF CURRENTLY ADMINISTERING CPS, GO TO BOX CPSBEG.
ELSE GO TO ASTATEMENT.
ST82
yes/no
IS THERE ANOTHER CHARGE BUNDLE FROM THIS (TYPE OF STATEMENT) OR ANOTHER MSN,
INSURANCE, TRICARE, OR MEDICARE PRESCRIPTION DRUG BENEFIT STATEMENT TO ENTER?
BOX STEND
routing
GO TO PSQ.
ASTATEMENT
Question Text/Description
Code List
Routing
(01) CONTINUOUS ANSWER
BOX ST80
(01) YES
(02) NO
(01) ST4 - MATCHST
(02) BOX STEND
Page 18 of 18
| File Type | application/pdf |
| Author | Shena Patel |
| File Modified | 2019-03-21 |
| File Created | 2018-11-29 |