|
1 |
BENE_ID |
Encrypted 723 CCW Beneficiary ID |
| 2 |
ASMT_ID |
Encrypted Assessment ID |
| 3 |
AST_BEG_VER_DT |
Assessment Beginning Version Date |
| 4 |
ASMT_CRCTN_VRSN_NUM |
Assessment Correction Version Number |
| 5 |
ASMT_END_VRSN_DT |
Assessment Ending Version Date |
| 6 |
AST_MOD_CD |
Assessment Modification Code |
| 7 |
CALC_HIPPS_CD |
Calculated HIPPS Code |
| 8 |
CREATED_DATE |
Created Date |
| 9 |
EFFECTIVE_DT |
Effective Date (Determines Year of Assessment) |
| 10 |
MCR_CMI |
Medicare CMI Value for RUG Group |
| 11 |
MCR_CODE_SET |
Medicare RUG CMI Set Used |
| 12 |
MCR_GP |
Medicare RUG Group |
| 13 |
MCR_VR |
Medicare RUG Version |
| 14 |
ORGNL_ASMT_ID |
Encrypted Original Assessment ID (MDS) |
| 15 |
PRVDR_INT_NUM |
Provider Internal Number |
| 16 |
REC_TYPE |
Record Type |
| 17 |
RES_CHG_TIMESTAMP |
Resident Data Update Timestamp |
| 18 |
RES_MATCH_CRITERIA |
Resident Match Criteria |
| 19 |
SB_ASMT_INT_ID |
Encrypted D170SB Assessment Internal ID |
| 20 |
SB_SUB_REQ |
SB Submission Requirement |
| 21 |
SB_SUBMSN_SQNC_NUM |
SB Submission Sequence Number |
| 22 |
SFTWR_ID |
Software ID |
| 23 |
SFT_VER |
Software Version |
| 24 |
STATE_CD |
Submitting State Alpha Abbreviation |
| 25 |
SUBMISSION_DATE |
Submission Date |
| 26 |
TRGT_DT |
Target Date |
| 27 |
UPDATED_DT |
Updated Date |
| 28 |
VRSN_CD1 |
Version Code 1 |
| 29 |
VRSN_CD2 |
Version Code 2 |
| 30 |
ETHNCTY_AMRCN_INDN_AK_NTV_SW |
(5a)Race: American Indian/Alaskan Native |
| 31 |
ETHNCTY_ASN_SW |
(5b)Race: Asian |
| 32 |
ETHNCTY_AFRCN_AMRCN_SW |
(5c)Race: Black or African American |
| 33 |
ETHNCTY_HSPNC_LTN_SW |
(5d)Ethnicity: Hispanic or Latino |
| 34 |
ETHNCTY_NTV_HI_PCFC_ISLNDR_SW |
(5e)Race: Native Hawaiian or other Pacific Islander |
| 35 |
ETHNCTY_WHT_SW |
(5f)Race: White |
| 36 |
ASMT_OMRA_SW |
(11c) OMRA Assessment |
| 37 |
ASMT_CLNCL_CHG_SW |
(11d) Clinical Change Assessment |
| 38 |
ASMT_STATE_RQRD_SW |
(11e) Assessment Required for State |
| 39 |
ASMT_OTHR_RSN_SW |
(11f) Assessment Needed Other Reasons |
| 40 |
PRIOR_ACUTE_CARE_ADMSN_DT |
(12) Prior Acute Care Admission Date |
| 41 |
ADMTD_FROM_CD |
(14a) Admitted From Code |
| 42 |
DSCHRG_STUS_CD |
(14b) Discharge Status Code |
| 43 |
REENTRY_FROM_CD |
(14c) Reentry From Code |
| 44 |
AA2_GENDER |
2(AA2) Gender |
| 45 |
AA3_BIRTH_DT |
3(AA3) Birthdate |
| 46 |
A5_MARITAL_STATUS |
4(A5) Marital Status |
| 47 |
AB4_PRIOR_ZIP |
6(AB4) ZIP Code of Pre-Hospital Residence |
| 48 |
AA6A_FAC_MCAID_NBR |
9a(AA6a) Hospital State Medicaid Provider Number |
| 49 |
AA6B_FAC_MCARE_NBR |
9b(AA6b) Hospital Medicare Provider Number |
| 50 |
A3A_ASMT_REF_DT |
10a(A3A) Assessment Reference Date |
| 51 |
AA8A_PRI_RFA |
11a(AA8A) Primary Reason for Assessment |
| 52 |
AA8B_SPC_RFA |
11b(AA8B) PPS Scheduled Assessments |
| 53 |
AB1_ADMSN_DT |
13(AB1)Admission Date |
| 54 |
R4_DISCHARGE_DT |
15(R4)Discharge Date |
| 55 |
A4A_REENTRY_DT |
16(A4a)Reentry Date |
| 56 |
B1_COMATOSE |
17(B1)Comatose |
| 57 |
B2A_ST_MEMORY |
18(B2A)Short Term Memory |
| 58 |
B4_DAY_DCSN_MAKING |
19(B4)Cognitive Skills |
| 59 |
C4_IS_UNDERSTOOD |
20(C4)Making Self Understood |
| 60 |
E1L_WORRIED_FACE |
21(E1l)Sad, Pained, Worried Facial Expressions |
| 61 |
E1A_NEG_STATE |
21a(E1A)Negative Statements |
| 62 |
E1B_REPEAT_QUES |
21b(E1B)Repetitive Questions |
| 63 |
E1C_REPEAT_VERB |
21c(E1C)Repetitive Verbalizations |
| 64 |
E1D_PRST_ANGER |
21d(E1d)Persistent Anger With Self/Others |
| 65 |
E1E_SELF_DEPER |
21e(E1e)Self Depreciation |
| 66 |
E1F_UNREAL_FEARS |
21f(E1f)Expression of Unrealistic Fears |
| 67 |
E1G_TERRIBLE_FEEL |
21g(E1g)Recurrent Statements of Terrible Future |
| 68 |
E1H_HLTH_COMPLAIN |
21h(E1h)Repetitive Health Complaints |
| 69 |
E1I_ANX_COMP |
21i(E1i)Repetitive Anxious Complaints/Concerns |
| 70 |
E1J_UNPLEAS_MORN |
21j(E1j)Unpleasant Mood in Morning |
| 71 |
E1K_INSOMNIA |
21k(E1k)Insomnia/Change in Sleeping Pattern |
| 72 |
E1M_CRYING |
21m(E1m)Crying/Tearfulness |
| 73 |
E1N_REPEAT_MOVES |
21n(E1n)Repetitive Physical Movements |
| 74 |
E1O_WITHDRAWN |
21o(E1o)Withdrawal From Activities of Interest |
| 75 |
E1P_LESS_INTERACT |
21p(E1p)Reduced Social Interaction |
| 76 |
E4AA_WANDERS |
22a(E4aA)Wandering: Frequency |
| 77 |
E4BA_VRBL_ABUSIVE |
22b(E4bA)Verbally Abusive Behavioral Symptoms: Frequency |
| 78 |
E4CA_PHYS_ABUSIVE |
22c(E4cA)Physically Abusive Behavioral Symptoms: Frequency |
| 79 |
E4DA_DIS_BEHAVIOR |
22d(E4dA)Socially Inappropriate/Disruptive Behavior: Frequency |
| 80 |
E4EA_RESIST_CARE |
22e(E4eA)Resists Care: Frequency |
| 81 |
G1AA_SELF_BED |
23aA(G1aA)Bed Mobility - Self Performance |
| 82 |
G1AB_SUPP_BED |
23aB(G1aB)Bed Mobility - Support Provided |
| 83 |
G1BA_SELF_TRANS |
23bA(G1bA)Transfer - Self Performance |
| 84 |
G1BB_SUPP_TRANS |
23bB(G1bB)Transfer - Support Provided |
| 85 |
G1HA_SELF_EAT |
23cA(G1hA)Eating - Self Performance |
| 86 |
G1HB_SUPP_EAT |
23cB(G1hB)Eating - Support Provided |
| 87 |
G1IA_SELF_TOILET |
23dA(G1iA)Toilet Use - Self Performance |
| 88 |
G1IB_SUPP_TOILET |
23dB(G1iB)Toilet Use - Support Provided |
| 89 |
H3A_TOILET_PLAN |
24a(H3a)Any Scheduled Toileting Plan |
| 90 |
H3B_BLADDER_TR |
24b(H3b)Bladder Retraining Program |
| 91 |
I1A_DIABETES |
25a(I1a)Diabetes Mellitus |
| 92 |
I1R_APHASIA |
25b(I1r)Aphasia |
| 93 |
I1S_CEREBRAL_PALSY |
25c(I1s)Cerebral Palsy |
| 94 |
I1V_HEMIPLEGIA |
25d(I1v)Hemiplegia/Hemiparesis |
| 95 |
I1W_M_S |
25e(I1w)Multiple Sclerosis |
| 96 |
I1Z_QUADRIPLEGIA |
25f(I1z)Quadriplegia |
| 97 |
I2E_PNEUMONIA |
26a(I2e)Pneumonia |
| 98 |
I2G_SEPTICEMIA |
26b(I2g)Septicemia |
| 99 |
J1C_DEHYDRATED |
27a(J1c)Dehydrated - Output Exceeds Input |
| 100 |
J1E_DELUSIONS |
27b(J1e)Delusions |
| 101 |
J1H_FEVER |
27c(J1h)Fever |
| 102 |
J1I_HALLUCINATIONS |
27d(J1i)Hallucinations |
| 103 |
J1J_INTERN_BLEED |
27e(J1j)Internal Bleeding |
| 104 |
J1O_VOMIT |
27f(J1o)Vomiting |
| 105 |
K3A_WEIGHT_LOSS |
28(K3a)Unplanned Weight Loss |
| 106 |
K5A_PARENTERAL_IV |
29a(K5a)Parenteral IV |
| 107 |
K5B_FEED_TUBE |
29b(K5b)Feeding Tube |
| 108 |
K6A_TOTAL_CALORIES |
30a(K6a)Parenteral or Enteral Intake |
| 109 |
K6B_FLUID_INTAKE |
30b(K6b)Average Fluid Intake In Last 7 Days |
| 110 |
M1A_STAGE_1_ULCER |
31a(M1a)Ulcers - Stage 1 |
| 111 |
M1B_STAGE_2_ULCER |
31b(M1b)Ulcers - Stage 2 |
| 112 |
M1C_STAGE_3_ULCER |
31c(M1c)Ulcers - Stage 3 |
| 113 |
M1D_STAGE_4_ULCER |
31d(M1d)Ulcers - Stage 4 |
| 114 |
M2A_PRES_ULCER |
32(M2a)Pressure Ulcer |
| 115 |
M4B_BURNS |
33a(M4b)Burns (Second or Third Degree) |
| 116 |
M4C_OPEN_LESIONS |
33b(M4c)Open Lesions Other Than Ulcers, Rashes, Cuts |
| 117 |
M4G_SURG_WOUND |
33c(M4g)Surgical Wounds |
| 118 |
M5A_RELIEF_CHAIR |
34a(M5a)Pressure Relieving Device(s) for Chair |
| 119 |
M5B_RELIEF_BED |
34b(M5b)Pressure Relieving Device(s) for Bed |
| 120 |
M5C_TURN_REPO |
34c(M5c)Turning/Repositioning Program |
| 121 |
M5D_INTER_SKIN_PROB |
34d(M5d)Nutrition/Hydration Intervention |
| 122 |
M5E_ULCER_CARE |
34e(M5e)Ulcer Care |
| 123 |
M5F_SURG_WOUND_CAR |
34f(M5f)Surgical Wound Care |
| 124 |
M5G_APP_DRESSINGS |
34g(M5g)Application of Dressings |
| 125 |
M5H_APP_MEDS |
34h(M5h)Application of Ointments/Medications |
| 126 |
M6B_INFECT_FOOT |
35a(M6b)Infection of the Foot |
| 127 |
M6C_LESIONS_FOOT |
35b(M6c)Open Lesions of the Foot |
| 128 |
M6F_DRESSINGS_FOOT |
35c(M6f)Application of Dressing (Foot) |
| 129 |
N1A_MORNING |
36a(N1a)Time Awake - Morning |
| 130 |
N1B_AFTERNOON |
36b(N1b)Time Awake - Afternoon |
| 131 |
N1C_EVENING |
36c(N1c)Time Awake - Evening |
| 132 |
O3_INJECTIONS |
37(O3)Injections |
| 133 |
P1AA_CHEMO |
38aa(P1aa)Special Care - Chemotherapy |
| 134 |
P1AB_DIALYSIS |
38ab(P1ab)Special Care - Dialysis |
| 135 |
P1AC_IV_MED |
38ac(P1ac)Special Care - IV Medication |
| 136 |
P1AG_OXYGEN |
38ad(P1ag)Special Care - Oxygen Therapy |
| 137 |
P1AH_RADIATION |
38ae(P1ah)Special Care - Radiation |
| 138 |
P1AI_SUCTION |
38af(P1ai)Special Care - Suctioning |
| 139 |
P1AJ_TRACH_CARE |
38ag(P1aj)Special Care - Tracheostomy Care |
| 140 |
P1AK_TRANSFUSION |
38ah(P1ak)Special Care - Transfusions |
| 141 |
P1AL_VENTILATOR |
38ai(P1al)Special Care - Ventilator or Respirator |
| 142 |
P1BAA_SPCH_THR_DAY |
38baA(P1baA)Speech Language Pathology & Audiology - Days |
| 143 |
P1BAB_SPCH_THR_MIN |
38baB(P1baB)Speech Language Pathology & Audiology - Minutes |
| 144 |
P1BBA_OCC_THPY_DAY |
38bbA(P1bbA)Occupational Therapy Days |
| 145 |
P1BBB_OCC_THPY_MIN |
38bbB(P1bbB)Occupational Therapy Minutes |
| 146 |
P1BCA_PHY_THPY_DAY |
38bcA(P1bcA)Physical Therapy Days |
| 147 |
P1BCB_PHY_THPY_MIN |
38bcB(P1bcB)Physical Therapy Minutes |
| 148 |
P1BDA_RES_THPY_DAY |
38bdA(P1bdA)Respiratory Therapy Days |
| 149 |
P1BDB_RES_THPY_MIN |
38bdB(P1bdB)Respiratory Therapy Minutes |
| 150 |
P3A_NR_MOTION_PASS |
39a(P3a)Nursing Rehab: Range of Motion (Passive) |
| 151 |
P3B_NR_MOTION_ACTV |
39b(P3b)Nursing Rehab: Range of Motion (Active) |
| 152 |
P3C_NR_SPLINT |
39c(P3c)Nursing Rehab: Splint/Brace Assistance |
| 153 |
P3D_NR_BED_MOBILE |
39d(P3d)Nursing Rehab: Bed Mobility |
| 154 |
P3E_NR_TRANSFER |
39e(P3e)Nursing Rehab: Transfer |
| 155 |
P3F_NR_WALKING |
39f(P3f)Nursing Rehab: Walking |
| 156 |
P3G_NR_DRESS_GROOM |
39g(P3g)Nursing Rehab: Dressing or Grooming |
| 157 |
P3H_NR_EATING |
39h(P3h)Nursing Rehab: Eating or Swallowing |
| 158 |
P3I_NR_AMPUTA_CARE |
39i(P3i)Nursing Rehab: Amputation/Prosthesis Care |
| 159 |
P3J_NR_COMMUNICAT |
39j(P3j)Nursing Rehab: Communication |
| 160 |
P7_PHYS_VISIT |
40(P7)Physician Visits |
| 161 |
P8_PHYS_ORDERS |
41(P8)Physician Orders |
| 162 |
T1B_ORDER_THPY |
42a(T1b)Ordered Therapies |
| 163 |
T1C_THPY_DAYS |
42b(T1c)Ordered Therapies - Days |
| 164 |
T1D_THPY_MIN |
42c(T1d)Ordered Therapies - Minutes |
| 165 |
T3MCARE_CALC_RUG |
43-Medicare (T3)Case Mix Group - Medicare |
| 166 |
T3STATE_CALC_RUG |
43-State(T3)Case Mix Group - State |
| 167 |
HIPPS_CD |
44HIPPS Code |
| 168 |
R2B_COMPLETE_DT |
45b(R2b)Signature Completion Date |
