Form CMS-10390 Hospice Item Set - Descriptions

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

Hospice Item Set: Item Descriptions
Item

Definition/Description

Section A: Administrative Information
Note: Items marked with an asterisk (*) are items that appear on both the Admission and Discharge Item Sets. Items
marked with two asterisks (**) are items that appear only on the Discharge Item Set.

Enter the one-digit code to indicate the type of record.
Code 1 if this is a new record that has not been previously submitted
and accepted in the QIES ASAP system.
A0050. Type of Record*

Code 2 if this is a request to modify the data for a record that has been
previously submitted and accepted in the QIES ASAP system.
Code 3 if this is a request to inactivate a record that already has been
submitted and accepted in the QIES ASAP system.

A0100. Facility Provider
Numbers. Enter code in boxes
provided.*

Record the NPI (National Provider Identification) number: 10 digits,
no spaces, no letters, no other characters.
Record the CCN (CMS Certification Number, also known as the
Medicare Provider Number): 6 digits, no spaces, no letters, no other
characters.

A0205. Site of Service at
Admission

Enter the two-digit code to indicate the patient’s site of service at the
time of admission to hospice.

A0220. Admission Date*

Record the admission date in MM-DD-YYYY format. For Medicare
patients, this date is the effective date of hospice benefit election.

A0245. Date Initial Nursing
Assessment Initiated

Record the date the hospice registered nurse began the initial
assessment, in MM-DD-YYYY format. This may or may not be the
same date as the admission date.
Enter the two-digit code that corresponds to reason for completing the
item set.

A0250. Reason for Record*

A0270. Discharge Date**

A0500. Legal Name of Patient*

Code 01 for Admission.
Code 09 for Discharge.
Record the date the patient was discharged, record the date in
MMDD-YYYY format. This is the date the patient leaves the hospice.
If the patient has expired, it is the date of death.
Record the patient’s legal name, as it appears on the Medicare card.
If the patient is not enrolled in the Medicare program, enter the
patient’s name as it appears on a Medicaid card or other government
issued document.

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Item

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Definition/Description
Record the patient’s Social Security and Medicare Numbers for
identification purposes.
If a patient does not have a Social Security Number, the item may be
left blank.

A0600. Social Security and
Medicare Numbers*

A0700. Medicaid Number Enter "+" if pending, "N" if not a
Medicaid Recipient*

A0800. Gender*

Enter the Medicare number exactly as it appears on the patient’s
Medicare card. If the patient does not have a Medicare number, a
Railroad Retirement Board (RRB) number may be substituted. If the
patient has neither a Medicare number nor an RRB number, the item
may be left blank.
Record the Medicaid number if the patient is a Medicaid recipient.
Enter a “+” in the left-most box if the number is pending.
Enter “N” in the left-most box if the patient is not a Medicaid recipient.
Enter the one-digit code for the patient’s gender.
Code 1 if the patient is male.
Code 2 if the patient is female.

A0900. Birth Date*

Record the birth date of the patient using MM-DD-YYYY format.

A1000. Race/Ethnicity (Check
all that apply)

Record the race/ethnicity of the patient. Check all that apply.

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

Enter the two-digit code that best describes the setting in which the
patient was staying immediately preceding this admission.

A2115. Reason for Discharge**

Enter the two-digit code to indicate the reason for discharge.

Section F: Preferences
F2000. CPR Preference

F2000A. Was the
patient/responsible party asked
about preference regarding the
use of cardiopulmonary
resuscitation (CPR)?

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Enter the one-digit code to indicate whether the
patient/responsible party was asked about preference regarding
the use of CPR. Code 0 if the patient/responsible party was not
asked about preference regarding the use of CPR.
Code 1 if the patient/family was asked about preference regarding the
use of CPR, and a discussion occurred.
Code 2 if the patient/responsible party was asked about preference
regarding the use of CPR, but the patient/responsible party refused to
discuss.

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Item

Definition/Description

F2000B. Date the
patient/responsible party was
first asked about preference
regarding the use of CPR

Record the date the patient/responsible party was first asked about
preference regarding the use of CPR in MM-DD-YYYY format.

Item

Definition/Description

F2100. Other Life-Sustaining
Treatment Preferences
Enter the one-digit code to indicate whether the patient/responsible
party was asked about preferences regarding life-sustaining
treatments other than CPR.
F2100A. Was the
patient/responsible party asked
about preferences regarding lifesustaining treatments other than
CPR?

F2100B. Date the
patient/responsible party was
first asked about preferences
regarding life-sustaining
treatments other than CPR.

Code 0 if the patient/responsible party was not asked about
preferences regarding life-sustaining treatments other than CPR.
Code 1 if the patient/responsible party was asked about preferences
regarding life-sustaining treatments other than CPR, and a discussion
occurred.
Code 2 if the patient/responsible party was asked about preferences
regarding life-sustaining treatments other than CPR, but the
patient/responsible party refused to discuss.

Record the date the patient/responsible party was first asked about
preferences regarding life-sustaining treatments other than CPR in
MM-DD-YYYY format.

F2200. Hospitalization
Preference

F2200A. Was the
patient/responsible party asked
about preference regarding
hospitalization?

F2200B. Date the
patient/responsible party was
asked about preference
regarding hospitalization

Enter the one-digit code to indicate whether the patient/responsible
party was asked about preference regarding hospitalization. Code
0 if the patient/responsible party was not asked about preference
regarding hospitalization.
Code 1 if the patient/responsible party was asked about preference
regarding hospitalization, and a discussion occurred.
Code 2 if the patient/responsible party was asked about preference for
hospitalization, but the patient/responsible party refused to discuss.

Record the date the patient/responsible party was first asked about
preference regarding hospitalization in MM-DD-YYYY format.

F3000. Spiritual/Existential
Concerns

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Item

Definition/Description
Enter the one-digit code to indicate whether the patient and/or
caregiver was asked about spiritual/existential concerns.

F3000A. Was patient and/or
caregiver asked about
spiritual/existential concerns?

Code 0 if the patient and/or caregiver was not asked about
spiritual/existential concerns.
Code 1 if the patient and/or caregiver was asked about
spiritual/existential concerns, and a discussion occurred. Code
2 if the patient and/or caregiver was asked about
spiritual/existential concerns, but the patient and/or caregiver refused
to discuss.

F3000B. Date patient and/or
caregiver was first asked about
spiritual/existential concerns

Record the date the patient and/or caregiver was first asked about
spiritual/existential concerns in MM-DD-YYYY format.

Item

Definition/Description

Section I: Active Diagnoses
Enter the two-digit code that best describes the patient’s principal
diagnosis.
Code 01 if the patient’s principal diagnosis is cancer.
Code 02 if the patient’s principal diagnosis is dementia/Alzheimer’s.
Code 99 if the patient’s principal diagnosis is a disease/condition other
than cancer or dementia/Alzheimer’s.

I0010. Principal Diagnosis

Section J: Health Conditions
Pain
J0900. Pain Screening

J0900A. Was the patient
screened for pain?

Enter the one-digit code to indicate whether or not the patient was
screened for pain. A pain screening includes activities to discern the
presence and severity of pain symptoms. Enter 0 if a pain screening
was not conducted.
Enter 1 if a pain screening was conducted.

J0900B. Date of first screening
for pain

Record the date in MM-DD-YYYY format of the first screening for pain.

J0900C. The
severity was:

patient’s

Enter the one-digit code to indicate the patient’s pain severity score.
Code 0 if the patient’s pain was none.
pain Code 1 if the patient’s pain was mild.
Code 2 if the patient’s pain was moderate.
Code 3 if the patient’s pain was severe.
Code 9 if the pain was not rated.
Enter the one-digit code to indicate the type of standardized pain tool
used.

J0900D. Type of standardized
pain tool used

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Code 1 if a numeric scale was used.
Code 2 if a verbal descriptor scale was used.
Code 3 if a patient visual scale was used.
Code 4 if a staff observation tool was used.
Code 9 if pain was not rated using a standardized tool.

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Item

Definition/Description

J0910. Comprehensive pain
assessment

J0910A. Was a comprehensive
pain assessment done?

Enter the one-digit code to indicate whether or not the patient had a
comprehensive pain assessment. A comprehensive pain assessment
includes activities to gain an understanding of the location, severity,
character, duration, frequency, and impact on function and what
relieves or worsens pain.
Enter 0 if a comprehensive pain assessment was not conducted.
Enter 1 if a comprehensive pain assessment was conducted.

J0910B. Date of comprehensive Record the date of comprehensive assessment of pain in MM-DDYYYY
pain assessment
format.

Item

Definition/Description

J0910C. Comprehensive pain
assessment included (Check all
that apply)

Record each characteristic included in the comprehensive pain
assessment. Check all that apply from:
1. Location
2. Severity
3. Character
4. Duration
5. Frequency
6. What relieves/worsens pain
7. Effect or function on quality of life
9. None of the above

Respiratory Status
J2030. Screening for Shortness
of Breath

J2030A. Was the patient
screened for shortness of
breath?

J2030B. Date of first screening
for shortness of breath

J2030C. Did the screening
indicate the patient had
shortness of breath?

Enter the one-digit code to indicate whether or not the patient was
screened for shortness of breath. A screening for shortness of breath
would include self-report questions or clinical observations to discern
the presence and severity of shortness of breath.
Enter 0 if the patient was not screened for shortness of breath.
Enter 1 if the patient was screened for shortness of breath.
Record the date in MM-DD-YYYY format of the first screening for
shortness of breath.
Enter the one-digit code to indicate whether the shortness of breath
screening indicated the patient has shortness of breath.
Code 0 if the screening indicated the patient did not have shortness
of breath.
Code 1 if the screening indicated the patient had shortness of breath.

J2040. Treatment for Shortness
of Breath

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Item

Definition/Description
Enter the one-digit code to indicate whether treatment for shortness
of breath was initiated. Treatment can include medication, equipment,
and/or non-medication interventions.

J2040A. Was treatment for
Enter 0 if the treatment for shortness of breath was not initiated.
shortness of breath initiated?
Enter 1 if patient declined treatment.
Enter 2 if treatment for shortness of breath was initiated.

Enter the date that treatment for shortness of breath was initiated in
MM-DD-YYYY format.
J2040B. Date treatment
shortness of breath initiated

for “Initiated” is defined as the date the order (verbal or written) was
received. For non-medication interventions, there may be no orders;
in this case, use the date the intervention was delivered.

J2040C. Type(s) of treatment
for shortness of breath initiated
(Check all that apply)

Indicate the type of treatment initiated for shortness of breath. Check
all that apply from:
1. Opioids
2. Other medication
3. Oxygen
4. Non-medication

Item

Definition/Description

Section N: Medications
N0500. Scheduled Opioid
Enter the one-digit code to indicate whether a scheduled opioid was
initiated or continued from the previous care setting.
N0500A. Was a scheduled
opioid initiated or continued?

Code 0 if a scheduled opioid was neither initiated nor continued from
the previous care setting.
Code 1 if a scheduled opioid was initiated or continued from the
previous care setting.
Indicate the date the scheduled opioid was initiated or continued in MMDD-YYYY format.

N0500B. Date scheduled opioid
The date should reflect the date the order (verbal or written) for the
initiated or continued
medication was received.
N0510. PRN Opioid
Enter the one-digit code to indicate whether a PRN opioid was
initiated or continued from the previous care setting.
N0510A. Was PRN opioid
initiated or continued?

Code 0 if a PRN opioid was neither initiated nor continued from the
previous care setting.
Code 1 if a PRN opioid was initiated or continued from the previous
care setting.

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Item

N0510B. Date PRN opioid
initiated or continued

Definition/Description
Indicate the date the PRN opioid was initiated or continued in MMDDYYYY format.
The date should reflect the date the order (verbal or written) for the
medication was received.

N0520. Bowel Regimen
Enter the one-digit code to indicate whether a bowel regimen was
initiated or continued from the previous care setting. A bowel regimen
is defined as a laxative or stool softener, a high fiber supplement, or a
high fiber diet.
Code 0 if the medical record indicates that a bowel regimen was
neither initiated nor continued from the previous care setting.

N0520A. Was a bowel regimen
Code 1 if the medical record indicates why a bowel regimen was not
initiated or continued?
initiated or continued. Documentation for why a bowel regimen was
not initiated or continued could include, but is not limited to: clinical
contraindication or patient declined treatment offered.
Code 2 if the medical record indicates a bowel regimen was either
initiated or continued from the previous care setting

N0520B. Date bowel regimen
initiated or continued

Item

Indicate the date the bowel regimen was initiated or continued in
MMDD-YYYY format.
The date should reflect the date the order (verbal or written) for the
bowel regimen was received.

Definition/Description

Section Z: Record Administration
Z0400. Signature(s) of
person(s) completing the
record.*

Z0500. Signature of Person
Verifying Record Completion*

All staff that completed any part of the Hospice Item Set should enter
their signature, title, section, or portion(s) of a section(s) they
completed, and the date completed. Each person who completed
any portion of the Hospice Item Set will need to sign Z0400.
The staff member verifying that then entire Hospice Item Set is
completed should sign and date Z0500 A and B.
The signature in Z0500 certifies that all sections are complete. The
person completing Z0500 is not certifying the accuracy of portions of
the record that were completed by other hospice staff members. For
Z0500B, use the actual date that the Hospice Item Set was
completed, reviewed, and signed as complete by an individual
authorized to do so.

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 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.

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