CMS-10390 Hospice Item Set - Admissions

HIS-Admission

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

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 09381153. The time required to complete this information collection is estimated to
average 19 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
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Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

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

Hospice Item Set - Admission
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):

A0205. Site of Service at Admission

Enter Code

01. Hospice in patient's home/residence
02. Hospice in Assisted Living facility
03. Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility
(NF)
04. Hospice provided in a Skilled Nursing Facility (SNF)
05. Hospice provided in Inpatient Hospital
06. Hospice provided in Inpatient Hospice Facility
07. Hospice provided in Long Term Care Hospital (LTCH)
08. Hospice in Inpatient Psychiatric Facility
09. Hospice provided in a place not otherwise specified (NOS)
10. Hospice home care provided in a hospice facility

A0220. Admission Date

Month

Day

Year

Month

Day

Year

A0245. Date Initial Nursing Assessment Initiated

A0250. Reason for Record
Enter Code

01. Admission
09. Discharge

Hospice Item Set – Admission
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Section A

Administrative Information

A0500. Legal Name of Patient
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0550. Patient ZIP Code. Enter code in boxes provided.
Patient ZIP Code:

-

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

Hospice Item Set – Admission
V3.00.0 Effective XX-XX-XXXX

Day

Year

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Section A

Administrative Information

A1000. Race/Ethnicity
 Check all that apply
A. American Indian or Alaska Native
B. Asian

C. Black or African American
D. Hispanic or Latino

E. Native Hawaiian or Other Pacific Islander
F. White

A1400. Payor Information
 Check all that apply
A. Medicare (traditional fee-for-service)

B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care)

G. Other government (e.g., TRICARE, VA, etc.)
H. Private Insurance/Medigap
I. Private managed care
J. Self-pay

K. No payor source
X. Unknown
Y. Other

A1802. Admitted From. Immediately preceding this admission, where was the patient?
Enter Code

01. Community residential setting (e.g., private home/apt., board/care, assisted living,
group home, adult foster care)
02. Long-term care facility
03. Skilled Nursing Facility (SNF)
04. Hospital emergency department
05. Short-stay acute hospital
06. Long-term care hospital (LTCH)
07. Inpatient rehabilitation facility or unit (IRF)
08. Psychiatric hospital or unit
09. ID/DD Facility
10. Hospice
99. None of the Above

Hospice Item Set – Admission
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Section F

Preferences

F2000. CPR Preference
Enter Code

A. Was the patient/responsible party asked about preference regarding the use of
cardiopulmonary resuscitation (CPR)? - Select the most accurate response
0. No  Skip to F2100, Other Life-Sustaining Treatment Preferences
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss

B. Date the patient/responsible party was first asked about preference regarding the
use of CPR:

Month

Day

Year

F2100. Other Life-Sustaining Treatment Preferences
Enter Code

A. Was the patient/responsible party asked about preferences regarding life-sustaining
treatments other than CPR? - Select the most accurate response
0. No  Skip to F2200, Hospitalization Preference
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about preferences regarding lifesustaining treatments other than CPR:

Month

Day

F2200. Hospitalization Preference
Enter Code

Year

A. Was the patient/responsible party asked about preference regarding
hospitalization? - Select the most accurate response
0. No  Skip to F3000, Spiritual/Existential Concerns
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss

B. Date the patient/responsible party was first asked about preference regarding
hospitalization:

Month

Day

F3000. Spiritual/Existential Concerns
Enter Code

Year

A. Was the patient and/or caregiver asked about spiritual/existential concerns? - Select
the most accurate response
0. No  Skip to I0010, Principal Diagnosis
1. Yes, and discussion occurred
2. Yes, but the patient and/or caregiver refused to discuss
B. Date the patient and/or caregiver was first asked about spiritual/existential
concerns:

Month

Hospice Item Set – Admission
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Day

Year

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Section I

Active Diagnoses

I0010. Principal Diagnosis
Enter Code

01. Cancer
02. Dementia/Alzheimer’s
99. None of the above

Hospice Item Set – Admission
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Section J

Health Conditions

Pain

J0900. Pain Screening
Enter Code

A. Was the patient screened for pain?
0. No  Skip to J0905, Pain Active Problem
1. Yes
B. Date of first screening for pain:

Enter Code

Enter Code

Month

Day

C. The patient’s pain severity was:
0. None
1. Mild
2. Moderate
3. Severe
9. Pain not rated

Year

D. Type of standardized pain tool used:
1. Numeric
2. Verbal descriptor
3. Patient visual
4. Staff observation
9. No standardized tool used

J0905. Pain Active Problem
Enter Code

Is pain an active problem for the patient?
0. No  Skip to J2030, Screening for Shortness of Breath
1. Yes

Hospice Item Set – Admission
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Section J

Health Conditions

J0910. Comprehensive Pain Assessment
Enter Code

A. Was a comprehensive pain assessment done?
0. No  Skip to J2030, Screening for Shortness of Breath
1. Yes
B. Date of comprehensive pain assessment:

Month

Day

Year

C. Comprehensive pain assessment included:

 Check all that apply
1. Location
2. Severity

3. Character
4. Duration

5. Frequency

6. What relieves/worsens pain

7. Effect on function or quality of life
9. None of the above

Hospice Item Set – Admission
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Section J

Health Conditions

Respiratory Status

J2030. Screening for Shortness of Breath
Enter Code

A. Was the patient screened for shortness of breath?
0. No  Skip to N0500, Scheduled Opioid
1. Yes

B. Date of first screening for shortness of breath:

Enter Code

Month

Day

Year

C. Did the screening indicate the patient had shortness of breath?
0. No  Skip to N0500, Scheduled Opioid
1. Yes

J2040. Treatment for Shortness of Breath
Enter Code

A. Was treatment for shortness of breath initiated? - Select the most accurate response
0. No  Skip to N0500, Scheduled Opioid
1. No, patient declined treatment  Skip to N0500, Scheduled Opioid
2. Yes

B. Date treatment for shortness of breath initiated:

Month

Day

Year

C. Type(s) of treatment for shortness of breath initiated:

 Check all that apply
1. Opioids

2. Other medication
3. Oxygen

4. Non-medication

Hospice Item Set – Admission
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Section N

Medications

N0500. Scheduled Opioid
Enter Code

A. Was a scheduled opioid initiated or continued?
0. No  Skip to N0510, PRN Opioid
1. Yes
B. Date scheduled opioid initiated or continued:

Month

N0510. PRN Opioid
Enter Code

Day

Year

A. Was a PRN opioid initiated or continued?
0. No  Skip to N0520, Bowel Regimen
1. Yes

B. Date PRN opioid initiated or continued:

Month

Day

N0520. Bowel Regimen
Complete only if N0500A or N0510A = 1
Enter Code

Year

A. Was a bowel regimen initiated or continued? - Select the most accurate response
0. No  Skip to Z0400, Signature(s) of Person(s) Completing the Record
1. No, but there is documentation of why a bowel regimen was not initiated or
continued  Skip to Z0400, Signature(s) of Person(s) Completing the Record
2. Yes
B. Date bowel regimen initiated or continued:

Month

Hospice Item Set – Admission
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Day

Year

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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

Hospice Item Set – Admission
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Day

Year

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