CMS-10199 CMS-10199.stent data entry

Facility Medicare Provider Number:
Record #

1
2
3
4
Etc.

Patient’s
Medicare
(HIC
Number of
NA)

Patient’s Date
of Birth
(MM/DD/YYYY)

Email Address:
Date of
Procedure
(MM/DD/YYYY)

Patient
Symptomatic
(Y/N)

Patient
Meets High
Surgical
Risk Criteria
(Y/N)

Modified
Rankin Scale
Score if
Patient
Experienced
Stroke PreProcedure (0
to 6 of NA)

Percent (%)
Stenosis by
Angiography
(0 to 99)

All fields are required. Column L indicated
missing/invalid data.
Percent
(%)
Stenosis of
Second
Lesion (0
to 99 or
NA)

Embolic
Protection
Used (Y/N)

Complications
During
Hospitalization
(y/N)

Missing or
Invalid Data
in
Column(s):

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 0938-1011 (Expires XX/XX/XXXX). This is a mandatory information collection. The time required to complete this
information collection is estimated to average 11 hours 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. *****CMS Disclaimer*****Please do not send
applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Sarah Fulton at [email protected].