CMS-P-0015A Telemedicine Questionnaire

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

TLQ-TELEMEDICINE

Question Text/Description

Code List

Routing

TELEMEDICINE QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007
SPALIVE=1
SEASON= WINTER
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after USQ.
BOX TLBEG

TELMED

TELMED

routing

code one

TELMEDT1

TELMEDT1

code one

TELMEDDU

TELMEDDU

code one

TELMEDT3

TELMEDT3

code one

TELMEDUS

TELMEDUS

code one

TELMEDT4

TELMEDT4

code one

BOX TLEND

routing

IF RESPONSE AT US1-PLACEPAR^=1, GO TO BOX TLEND
ELSE, GO TO TELMED
Does [your/(SP)’s] usual provider offer telephone or video appointments, so that [you don’t/he doesn't/she doesn’t]
need to physically visit their office or facility?

(01) TELMEDT1
(02) BOX TLEND
[IF NEEDED: Did [your/(SP)’s] provider offer to talk to [you/him/her] about [your/his/her] symptoms over the phone or
(-8) BOX TLEND
video so that [you/he/she] wouldn’t have to visit their office or facility?]
(-9) BOX TLEND
[IF NEEDED: Telephone appointments may include “audio-only” appointments.]
Do they offer telephone appointments, video appointments, or both?

TELMEDDU
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT “TELEPHONE”.
Since (TODAY'S MONTH AND YEAR-12 MONTHS), did [your/(SP)’s] usual provider offer [you/him/her] a telephone (01) TELMEDT3
(02) TELMEDUS
or video appointment to replace a regularly scheduled appointment?
(-8) TELMEDUS
(-9) TELMEDUS
[IF NEEDED: Telephone appointments may include “audio-only” appointments.]
Did they offer telephone appointments, video appointments, or both?
TELMEDUS
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT “TELEPHONE”.
(01) TELMEDT4
Since (TODAY'S MONTH AND YEAR-12 MONTHS), [have you/has (SP)] had an appointment with a doctor or other
(02) BOX TLEND
health professional by telephone or video?
(-8) BOX TLEND
(-9) BOX TLEND
[IF NEEDED: Telephone appointments may include “audio-only” appointments.]
Was it a telephone appointment, video appointment or both?
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT “TELEPHONE”.
IF ROUND = WINTER 2022 ROUND 92 AND 11TH ROUND INTERVIEW AND (INTTYPE IN C001) AND
(MREFDATE) IS AFTER (JANUARY 1 (CURRENT YEAR)) GO TO ACQ.

BOX TLEND

ELSE IF ROUND = WINTER 2022 ROUND 92 AND INTTYPE in (C001, C002, C004, C005, C006, C007, C010),
GO TO DVH.
IF 11TH ROUND INTERVIEW GO TO PXQ
ELSE, GO TO END.

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