CMS-10390 Hospice Item Set - Discharge

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

HIS-Discharge

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 9 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.

Hospice Item Set – Discharge
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):

A0220. Admission Date

Month

Day

Year

Day

Year

A0250. Reason for Record
Enter Code

01. Admission
09. Discharge

A0270. Discharge Date

Month

A0500. Legal Name of Patient
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

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

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Section A

Administrative Information

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

Day

Year

A2115. Reason for Discharge
Enter Code

01. Expired
02. Revoked
03. No longer terminally ill
04. Moved out of hospice service area
05. Transferred to another hospice
06. Discharged for cause

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

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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 – Discharge
V3.00.0 Effective XX-XX-XXXX

Day

Year

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