CMS-10390 Hospice Item Set - Discharge

HOPE Discharge (DC)

OMB Control Number XXXX-XXXX
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. HOPE is a patient assessment instrument that
intends to collect data during a hospice patient’s stay. Data collected using this instrument will be used to
measure the quality of care provided by a hospice provider. The valid OMB control number for this information
collection is XXXX-XXXX. Submission of this data is required by Section 1814(i)(5) of the Social Security Act.
The time required to complete this data collection is estimated to average XX minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and
review the data collected. Submitted patient-level data will remain confidential and is protected from public
dissemination in accordance with the Privacy Act of 1974, as amended. 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.
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 Jermama Keys, National Coordinator, Hospice Quality Reporting Program Centers
for Medicare & Medicaid Services, at [email protected].

HOPE Discharge (DC)
Centers for Medicare & Medicaid Services

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DISCHARGE TIMEPOINT - HOPE Version 1
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
A. National Provider Identifier (NPI):

CMS Certification Number (CCN):

B.

A0220. Admission Date

 Month    Day      Year
A0250. Reason for Record
Enter Code

1.  Admission (ADM)
2.  HOPE Update Visit 1 (HUV1)
3.  HOPE Update Visit 2 (HUV2)
9.  Discharge (DC)

A0270. Discharge Date

 Month    Day      Year

HOPE Discharge (DC)
Centers for Medicare & Medicaid Services

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A0500. Legal Name of Patient
A. First name:

B.

Middle initial:

C.

Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers
A. Social Security Number:

-

B.

-

Medicare 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

HOPE Discharge (DC)
Centers for Medicare & Medicaid Services

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A2115. Reason for Discharge
Enter Code

1.
2.
3.
4.
5.
6.

Section Z

Expired
Revoked
No longer terminally ill
Moved out of hospice service area
Transferred to another hospice
Discharged for cause

Assessment 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 payment reduction in
the Fiscal Year payment determination. I also certify that I am authorized to submit this information by this provider on its behalf.
Signatures

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.

___________________________________________________
B.

Signature

Date

Month    Day      Year

HOPE Discharge (DC)
Centers for Medicare & Medicaid Services

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