*** Effective Date: 9/18/2025   The following required for Bulk Import: |||
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|1
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|1
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|1
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|1
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|1
6|(M0040) Patient First Name:|(M0040) Patient First Name:|1
7|(M0040) Patient Last Name|(M0040) Patient Last Name|1
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|1
9|(M0040) Patient Suffix|(M0040) Patient Suffix|1
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|1
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|1
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|1
13|(M0064) Social Security Number:|(M0064) Social Security Number:|1
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|1
15|(M0066) Birth Date:|(M0066) Birth Date:|1
16|(M0069) Gender:|(M0069) Gender:|1
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|1
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|1
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|1
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|1
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|1
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|1
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|1
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|1
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|1
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|1
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|1
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|1
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|1
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|1
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|1
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|1
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|1
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|1
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|1
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|1
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|1
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|1
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|1
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|1
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|1
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|1
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|1
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|1
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|1
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|1
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|1
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|1
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|1
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|1
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|1
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|1
53|(M0300) Current Residence:|(M0300) Current Residence:|1
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|1
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|1
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|1
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|1
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|1
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|1
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|1
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|1
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|1
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|1
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|1
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|1
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|1
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|1
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|1
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|1
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|1
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|1
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|1
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|1
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|1
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|1
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|1
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|1
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|1
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|1
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|1
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|1
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|1
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|1
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|1
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|1
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|1
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|1
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|1
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|1
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|1
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|1
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|1
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|1
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|1
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|1
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|1
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|1
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|1
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|1
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|1
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|1
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|1
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|1
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|1
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|1
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|1
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|1
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|1
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|1
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|1
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|1
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|1
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|1
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|1
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|1
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|1
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|1
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|1
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|1
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|1
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|1
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|1
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|1
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|1
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|1
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|1
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|1
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|1
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|1
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|1
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|1
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|1
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|1
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|1
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|1
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|1
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|1
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|1
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|1
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|1
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|1
144|Wound Care|Wound Care|1
145|Great presidential Moments|Great presidential Moments|1
147|(M0110) Episode Timing|(M0110) Episode Timing|1
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|1
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|1
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|1
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|1
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|1
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|1
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|1
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|1
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|1
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|1
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|1
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|1
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|1
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|1
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|3
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|3
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|3
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|3
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|3
6|(M0040) Patient First Name:|(M0040) Patient First Name:|3
7|(M0040) Patient Last Name|(M0040) Patient Last Name|3
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|3
9|(M0040) Patient Suffix|(M0040) Patient Suffix|3
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|3
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|3
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|3
13|(M0064) Social Security Number:|(M0064) Social Security Number:|3
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|3
15|(M0066) Birth Date:|(M0066) Birth Date:|3
16|(M0069) Gender:|(M0069) Gender:|3
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|3
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|3
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|3
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|3
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|3
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|3
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|3
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|3
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|3
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|3
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|3
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|3
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|3
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|3
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|3
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|3
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|3
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|3
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|3
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|3
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|3
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|3
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|3
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|3
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|3
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|3
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|3
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|3
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|3
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|3
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|3
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|3
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|3
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|3
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|3
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|3
53|(M0300) Current Residence:|(M0300) Current Residence:|3
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|3
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|3
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|3
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|3
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|3
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|3
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|3
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|3
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|3
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|3
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|3
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|3
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|3
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|3
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|3
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|3
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|3
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|3
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|3
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|3
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|3
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|3
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|3
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|3
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|3
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|3
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|3
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|3
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|3
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|3
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|3
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|3
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|3
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|3
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|3
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|3
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|3
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|3
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|3
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|3
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|3
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|3
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|3
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|3
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|3
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|3
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|3
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|3
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|3
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|3
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|3
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|3
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|3
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|3
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|3
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|3
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|3
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|3
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|3
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|3
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|3
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|3
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|3
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|3
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|3
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|3
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|3
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|3
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|3
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|3
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|3
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|3
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|3
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|3
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|3
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|3
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|3
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|3
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|3
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|3
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|3
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|3
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|3
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|3
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|3
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|3
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|3
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|3
144|Wound Care|Wound Care|3
145|Great presidential Moments|Great presidential Moments|3
147|(M0110) Episode Timing|(M0110) Episode Timing|3
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|3
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|3
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|3
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|3
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|3
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|3
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|3
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|3
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|3
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|3
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|3
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|3
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|3
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|3
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|4
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|4
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|4
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|4
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|4
6|(M0040) Patient First Name:|(M0040) Patient First Name:|4
7|(M0040) Patient Last Name|(M0040) Patient Last Name|4
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|4
9|(M0040) Patient Suffix|(M0040) Patient Suffix|4
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|4
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|4
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|4
13|(M0064) Social Security Number:|(M0064) Social Security Number:|4
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|4
15|(M0066) Birth Date:|(M0066) Birth Date:|4
16|(M0069) Gender:|(M0069) Gender:|4
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|4
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|4
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|4
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|4
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|4
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|4
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|4
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|4
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|4
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|4
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|4
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|4
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|4
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|4
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|4
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|4
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|4
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|4
144|Wound Care|Wound Care|4
145|Great presidential Moments|Great presidential Moments|4
147|(M0110) Episode Timing|(M0110) Episode Timing|4
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|4
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|4
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|4
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|4
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|4
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|4
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|4
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|4
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|4
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|4
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|4
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|4
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|4
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|4
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|4
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|4
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|4
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|4
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|4
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|4
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|4
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|4
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|4
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|4
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|4
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|4
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|4
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|4
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|4
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|4
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|4
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|4
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|4
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|4
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|4
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|4
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|4
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|4
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|4
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|4
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|4
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|4
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|4
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|4
53|(M0300) Current Residence:|(M0300) Current Residence:|4
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|4
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|4
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|4
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|4
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|4
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|4
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|4
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|4
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|4
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|4
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|4
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|4
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|4
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|4
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|4
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|4
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|4
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|4
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|4
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|4
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|4
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|4
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|4
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|4
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|4
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|4
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|4
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|4
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|4
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|4
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|4
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|4
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|4
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|4
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|4
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|4
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|4
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|4
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|4
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|4
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|4
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|4
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|4
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|4
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|4
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|4
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|4
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|4
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|4
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|4
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|4
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|4
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|4
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|4
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|4
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|4
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|4
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|4
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|4
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|4
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|4
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|4
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|4
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|4
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|4
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|4
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|4
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|4
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|4
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|4
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|4
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|4
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|4
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|4
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|4
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|4
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|5
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|5
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|5
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|5
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|5
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|5
6|(M0040) Patient First Name:|(M0040) Patient First Name:|5
7|(M0040) Patient Last Name|(M0040) Patient Last Name|5
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|5
9|(M0040) Patient Suffix|(M0040) Patient Suffix|5
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|5
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|5
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|5
13|(M0064) Social Security Number:|(M0064) Social Security Number:|5
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|5
15|(M0066) Birth Date:|(M0066) Birth Date:|5
16|(M0069) Gender:|(M0069) Gender:|5
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|5
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|5
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|5
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|5
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|5
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|5
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|5
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|5
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|5
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|5
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|5
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|5
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|5
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|5
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|5
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|5
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|5
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|5
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|5
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|5
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|5
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|5
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|5
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|5
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|5
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|5
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|5
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|5
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|5
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|5
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|5
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|5
53|(M0300) Current Residence:|(M0300) Current Residence:|5
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|5
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|5
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|5
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|5
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|5
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|5
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|5
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|5
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|5
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|5
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|5
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|5
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|5
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|5
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|5
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|5
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|5
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|5
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|5
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|5
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|5
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|5
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|5
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|5
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|5
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|5
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|5
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|5
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|5
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|5
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|5
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|5
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|5
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|5
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|5
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|5
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|5
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|5
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|5
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|5
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|5
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|5
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|5
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|5
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|5
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|5
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|5
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|5
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|5
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|5
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|5
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|5
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|5
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|5
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|5
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|5
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|5
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|5
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|5
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|5
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|5
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|5
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|5
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|5
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|5
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|5
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|5
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|5
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|5
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|5
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|5
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|5
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|5
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|5
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|5
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|5
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|5
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|5
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|5
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|5
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|5
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|5
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|5
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|5
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|5
144|Wound Care|Wound Care|5
145|Great presidential Moments|Great presidential Moments|5
147|(M0110) Episode Timing|(M0110) Episode Timing|5
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|5
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|5
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|5
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|5
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|5
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|5
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|5
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|5
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|5
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|5
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|5
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|5
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|5
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|5
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|5
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|5
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|5
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|5
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|5
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|5
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|6
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|6
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|6
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|6
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|6
6|(M0040) Patient First Name:|(M0040) Patient First Name:|6
7|(M0040) Patient Last Name|(M0040) Patient Last Name|6
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|6
9|(M0040) Patient Suffix|(M0040) Patient Suffix|6
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|6
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|6
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|6
13|(M0064) Social Security Number:|(M0064) Social Security Number:|6
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|6
15|(M0066) Birth Date:|(M0066) Birth Date:|6
16|(M0069) Gender:|(M0069) Gender:|6
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|6
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|6
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|6
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|6
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|6
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|6
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|6
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|6
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|6
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|6
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|6
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|6
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|6
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|6
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|6
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|6
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|6
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|6
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|6
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|6
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|6
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|6
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|6
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|6
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|6
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|6
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|6
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|6
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|6
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|6
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|6
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|6
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|6
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|6
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|6
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|6
53|(M0300) Current Residence:|(M0300) Current Residence:|6
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|6
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|6
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|6
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|6
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|6
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|6
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|6
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|6
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|6
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|6
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|6
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|6
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|6
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|6
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|6
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|6
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|6
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|6
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|6
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|6
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|6
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|6
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|6
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|6
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|6
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|6
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|6
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|6
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|6
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|6
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|6
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|6
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|6
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|6
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|6
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|6
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|6
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|6
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|6
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|6
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|6
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|6
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|6
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|6
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|6
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|6
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|6
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|6
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|6
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|6
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|6
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|6
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|6
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|6
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|6
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|6
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|6
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|6
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|6
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|6
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|6
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|6
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|6
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|6
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|6
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|6
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|6
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|6
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|6
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|6
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|6
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|6
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|6
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|6
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|6
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|6
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|6
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|6
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|6
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|6
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|6
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|6
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|6
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|6
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|6
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|6
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|6
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|6
144|Wound Care|Wound Care|6
145|Great presidential Moments|Great presidential Moments|6
147|(M0110) Episode Timing|(M0110) Episode Timing|6
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|6
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|6
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|6
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|6
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|6
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|6
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|6
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|6
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|6
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|6
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|6
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|6
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|6
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|6
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|7
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|7
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|7
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|7
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|7
6|(M0040) Patient First Name:|(M0040) Patient First Name:|7
7|(M0040) Patient Last Name|(M0040) Patient Last Name|7
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|7
9|(M0040) Patient Suffix|(M0040) Patient Suffix|7
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|7
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|7
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|7
13|(M0064) Social Security Number:|(M0064) Social Security Number:|7
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|7
15|(M0066) Birth Date:|(M0066) Birth Date:|7
16|(M0069) Gender:|(M0069) Gender:|7
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|7
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|7
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|7
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|7
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|7
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|7
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|7
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|7
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|7
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|7
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|7
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|7
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|7
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|7
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|7
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|7
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|7
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|7
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|7
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|7
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|7
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|7
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|7
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|7
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|7
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|7
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|7
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|7
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|7
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|7
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|7
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|7
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|7
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|7
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|7
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|7
53|(M0300) Current Residence:|(M0300) Current Residence:|7
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|7
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|7
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|7
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|7
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|7
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|7
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|7
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|7
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|7
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|7
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|7
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|7
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|7
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|7
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|7
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|7
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|7
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|7
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|7
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|7
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|7
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|7
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|7
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|7
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|7
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|7
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|7
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|7
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|7
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|7
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|7
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|7
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|7
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|7
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|7
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|7
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|7
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|7
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|7
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|7
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|7
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|7
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|7
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|7
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|7
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|7
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|7
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|7
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|7
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|7
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|7
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|7
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|7
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|7
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|7
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|7
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|7
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|7
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|7
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|7
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|7
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|7
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|7
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|7
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|7
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|7
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|7
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|7
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|7
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|7
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|7
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|7
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|7
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|7
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|7
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|7
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|7
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|7
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|7
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|7
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|7
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|7
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|7
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|7
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|7
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|7
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|7
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|7
144|Wound Care|Wound Care|7
145|Great presidential Moments|Great presidential Moments|7
147|(M0110) Episode Timing|(M0110) Episode Timing|7
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|7
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|7
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|7
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|7
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|7
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|7
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|7
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|7
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|7
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|7
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|7
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|7
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|7
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|7
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|8
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|8
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|8
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|8
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|8
6|(M0040) Patient First Name:|(M0040) Patient First Name:|8
7|(M0040) Patient Last Name|(M0040) Patient Last Name|8
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|8
9|(M0040) Patient Suffix|(M0040) Patient Suffix|8
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|8
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|8
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|8
13|(M0064) Social Security Number:|(M0064) Social Security Number:|8
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|8
15|(M0066) Birth Date:|(M0066) Birth Date:|8
16|(M0069) Gender:|(M0069) Gender:|8
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|8
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|8
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|8
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|8
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|8
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|8
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|8
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|8
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|8
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|8
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|8
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|8
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|8
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|8
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|8
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|8
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|8
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|8
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|8
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|8
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|8
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|8
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|8
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|8
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|8
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|8
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|8
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|8
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|8
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|8
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|8
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|8
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|8
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|8
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|8
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|8
53|(M0300) Current Residence:|(M0300) Current Residence:|8
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|8
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|8
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|8
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|8
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|8
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|8
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|8
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|8
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|8
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|8
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|8
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|8
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|8
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|8
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|8
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|8
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|8
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|8
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|8
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|8
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|8
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|8
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|8
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|8
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|8
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|8
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|8
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|8
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|8
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|8
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|8
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|8
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|8
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|8
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|8
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|8
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|8
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|8
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|8
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|8
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|8
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|8
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|8
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|8
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|8
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|8
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|8
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|8
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|8
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|8
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|8
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|8
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|8
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|8
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|8
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|8
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|8
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|8
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|8
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|8
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|8
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|8
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|8
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|8
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|8
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|8
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|8
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|8
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|8
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|8
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|8
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|8
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|8
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|8
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|8
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|8
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|8
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|8
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|8
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|8
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|8
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|8
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|8
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|8
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|8
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|8
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|8
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|8
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|8
144|Wound Care|Wound Care|8
145|Great presidential Moments|Great presidential Moments|8
147|(M0110) Episode Timing|(M0110) Episode Timing|8
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|8
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|8
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|8
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|8
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|8
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|8
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|8
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|8
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|8
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|8
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|8
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|8
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|8
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|9
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|9
6|(M0040) Patient First Name:|(M0040) Patient First Name:|9
7|(M0040) Patient Last Name|(M0040) Patient Last Name|9
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|9
9|(M0040) Patient Suffix|(M0040) Patient Suffix|9
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|9
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|9
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|9
13|(M0064) Social Security Number:|(M0064) Social Security Number:|9
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|9
15|(M0066) Birth Date:|(M0066) Birth Date:|9
16|(M0069) Gender:|(M0069) Gender:|9
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|9
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|9
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|9
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|9
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|9
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|9
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|9
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|9
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|9
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|9
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|9
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|9
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|9
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|9
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|9
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|9
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|9
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|9
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|9
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|9
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|9
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|9
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|9
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|9
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|9
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|9
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|9
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|9
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|9
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|9
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|9
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|9
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|9
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|9
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|9
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|9
53|(M0300) Current Residence:|(M0300) Current Residence:|9
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|9
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|9
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|9
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|9
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|9
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|9
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|9
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|9
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|9
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|9
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|9
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|9
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|9
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|9
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|9
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|9
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|9
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|9
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|9
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|9
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|9
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|9
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|9
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|9
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|9
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|9
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|9
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|9
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|9
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|9
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|9
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|9
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|9
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|9
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|9
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|9
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|9
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|9
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|9
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|9
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|9
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|9
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|9
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|9
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|9
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|9
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|9
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|9
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|9
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|9
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|9
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|9
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|9
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|9
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|9
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|9
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|9
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|9
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|9
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|9
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|9
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|9
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|9
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|9
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|9
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|9
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|9
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|9
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|9
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|9
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|9
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|9
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|9
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|9
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|9
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|9
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|9
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|9
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|9
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|9
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|9
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|9
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|9
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|9
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|9
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|9
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|9
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|9
144|Wound Care|Wound Care|9
145|Great presidential Moments|Great presidential Moments|9
147|(M0110) Episode Timing|(M0110) Episode Timing|9
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|9
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|9
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|9
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|9
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|9
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|9
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|9
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|9
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|9
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|9
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|9
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|9
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|9
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|9
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|9
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|9
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|9
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|11
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|11
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|11
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|11
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|11
6|(M0040) Patient First Name:|(M0040) Patient First Name:|11
7|(M0040) Patient Last Name|(M0040) Patient Last Name|11
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|11
9|(M0040) Patient Suffix|(M0040) Patient Suffix|11
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|11
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|11
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|11
13|(M0064) Social Security Number:|(M0064) Social Security Number:|11
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|11
15|(M0066) Birth Date:|(M0066) Birth Date:|11
16|(M0069) Gender:|(M0069) Gender:|11
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|11
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|11
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|11
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|11
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|11
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|11
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|11
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|11
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|11
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|11
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|11
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|11
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|11
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|11
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|11
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|11
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|11
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|11
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|11
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|11
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|11
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|11
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|11
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|11
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|11
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|11
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|11
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|11
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|11
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|11
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|11
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|11
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|11
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|11
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|11
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|11
53|(M0300) Current Residence:|(M0300) Current Residence:|11
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|11
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|11
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|11
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|11
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|11
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|11
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|11
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|11
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|11
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|11
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|11
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|11
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|11
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|11
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|11
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|11
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|11
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|11
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|11
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|11
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|11
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|11
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|11
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|11
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|11
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|11
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|11
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|11
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|11
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|11
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|11
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|11
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|11
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|11
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|11
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|11
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|11
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|11
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|11
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|11
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|11
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|11
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|11
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|11
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|11
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|11
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|11
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|11
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|11
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|11
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|11
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|11
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|11
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|11
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|11
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|11
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|11
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|11
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|11
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|11
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|11
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|11
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|11
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|11
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|11
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|11
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|11
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|11
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|11
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|11
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|11
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|11
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|11
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|11
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|11
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|11
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|11
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|11
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|11
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|11
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|11
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|11
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|11
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|11
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|11
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|11
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|11
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|11
144|Wound Care|Wound Care|11
145|Great presidential Moments|Great presidential Moments|11
147|(M0110) Episode Timing|(M0110) Episode Timing|11
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|11
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|11
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|11
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|11
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|11
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|11
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|11
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|11
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|11
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|11
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|11
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|11
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|11
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|11
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|13
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|13
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|13
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|13
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|13
6|(M0040) Patient First Name:|(M0040) Patient First Name:|13
7|(M0040) Patient Last Name|(M0040) Patient Last Name|13
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|13
9|(M0040) Patient Suffix|(M0040) Patient Suffix|13
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|13
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|13
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|13
13|(M0064) Social Security Number:|(M0064) Social Security Number:|13
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|13
15|(M0066) Birth Date:|(M0066) Birth Date:|13
16|(M0069) Gender:|(M0069) Gender:|13
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|13
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|13
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|13
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|13
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|13
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|13
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|13
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|13
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|13
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|13
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|13
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|13
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|13
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|13
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|13
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|13
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|13
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|13
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|13
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|13
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|13
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|13
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|13
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|13
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|13
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|13
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|13
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|13
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|13
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|13
53|(M0300) Current Residence:|(M0300) Current Residence:|13
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|13
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|13
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|13
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|13
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|13
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|13
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|13
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|13
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|13
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|13
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|13
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|13
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|13
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|13
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|13
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|13
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|13
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|13
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|13
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|13
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|13
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|13
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|13
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|13
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|13
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|13
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|13
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|13
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|13
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|13
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|13
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|13
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|13
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|13
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|13
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|13
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|13
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|13
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|13
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|13
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|13
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|13
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|13
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|13
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|13
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|13
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|13
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|13
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|13
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|13
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|13
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|13
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|13
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|13
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|13
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|13
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|13
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|13
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|13
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|13
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|13
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|13
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|13
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|13
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|13
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|13
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|13
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|13
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|13
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|13
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|13
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|13
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|13
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|13
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|13
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|13
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|13
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|13
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|13
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|13
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|13
144|Wound Care|Wound Care|13
145|Great presidential Moments|Great presidential Moments|13
147|(M0110) Episode Timing|(M0110) Episode Timing|13
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|13
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|13
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|13
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|13
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|13
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|13
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|13
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|13
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|13
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|13
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|13
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|13
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|13
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|13
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|13
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|13
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|13
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|13
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|13
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|13
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|13
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|13
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|13
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|13
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|13
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|13
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|13
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|14
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|14
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|14
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|14
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|14
6|(M0040) Patient First Name:|(M0040) Patient First Name:|14
7|(M0040) Patient Last Name|(M0040) Patient Last Name|14
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|14
9|(M0040) Patient Suffix|(M0040) Patient Suffix|14
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|14
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|14
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|14
13|(M0064) Social Security Number:|(M0064) Social Security Number:|14
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|14
15|(M0066) Birth Date:|(M0066) Birth Date:|14
16|(M0069) Gender:|(M0069) Gender:|14
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|14
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|14
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|14
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|14
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|14
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|14
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|14
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|14
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|14
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|14
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|14
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|14
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|14
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|14
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|14
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|14
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|14
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|14
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|14
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|14
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|14
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|14
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|14
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|14
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|14
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|14
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|14
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|14
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|14
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|14
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|14
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|14
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|14
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|14
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|14
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|14
53|(M0300) Current Residence:|(M0300) Current Residence:|14
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|14
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|14
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|14
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|14
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|14
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|14
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|14
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|14
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|14
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|14
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|14
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|14
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|14
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|14
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|14
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|14
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|14
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|14
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|14
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|14
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|14
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|14
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|14
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|14
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|14
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|14
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|14
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|14
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|14
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|14
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|14
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|14
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|14
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|14
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|14
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|14
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|14
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|14
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|14
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|14
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|14
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|14
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|14
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|14
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|14
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|14
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|14
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|14
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|14
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|14
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|14
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|14
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|14
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|14
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|14
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|14
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|14
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|14
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|14
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|14
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|14
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|14
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|14
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|14
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|14
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|14
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|14
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|14
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|14
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|14
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|14
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|14
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|14
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|14
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|14
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|14
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|14
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|14
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|14
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|14
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|14
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|14
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|14
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|14
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|14
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|14
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|14
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|14
144|Wound Care|Wound Care|14
145|Great presidential Moments|Great presidential Moments|14
147|(M0110) Episode Timing|(M0110) Episode Timing|14
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|14
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|14
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|14
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|14
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|14
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|14
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|14
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|14
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|14
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|14
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|14
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|14
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|14
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|14
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|15
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|15
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|15
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|15
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|15
6|(M0040) Patient First Name:|(M0040) Patient First Name:|15
7|(M0040) Patient Last Name|(M0040) Patient Last Name|15
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|15
9|(M0040) Patient Suffix|(M0040) Patient Suffix|15
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|15
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|15
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|15
13|(M0064) Social Security Number:|(M0064) Social Security Number:|15
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|15
15|(M0066) Birth Date:|(M0066) Birth Date:|15
16|(M0069) Gender:|(M0069) Gender:|15
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|15
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|15
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|15
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|15
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|15
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|15
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|15
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|15
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|15
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|15
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|15
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|15
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|15
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|15
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|15
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|15
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|15
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|15
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|15
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|15
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|15
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|15
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|15
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|15
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|15
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|15
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|15
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|15
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|15
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|15
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|15
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|15
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|15
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|15
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|15
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|15
53|(M0300) Current Residence:|(M0300) Current Residence:|15
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|15
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|15
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|15
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|15
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|15
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|15
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|15
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|15
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|15
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|15
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|15
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|15
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|15
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|15
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|15
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|15
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|15
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|15
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|15
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|15
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|15
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|15
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|15
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|15
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|15
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|15
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|15
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|15
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|15
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|15
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|15
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|15
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|15
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|15
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|15
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|15
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|15
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|15
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|15
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|15
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|15
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|15
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|15
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|15
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|15
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|15
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|15
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|15
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|15
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|15
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|15
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|15
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|15
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|15
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|15
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|15
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|15
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|15
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|15
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|15
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|15
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|15
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|15
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|15
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|15
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|15
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|15
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|15
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|15
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|15
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|15
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|15
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|15
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|15
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|15
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|15
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|15
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|15
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|15
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|15
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|15
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|15
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|15
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|15
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|15
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|15
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|15
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|15
144|Wound Care|Wound Care|15
145|Great presidential Moments|Great presidential Moments|15
147|(M0110) Episode Timing|(M0110) Episode Timing|15
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|15
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|15
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|15
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|15
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|15
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|15
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|15
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|15
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|15
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|15
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|15
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|15
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|15
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|15
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|16
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|16
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|16
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|16
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|16
6|(M0040) Patient First Name:|(M0040) Patient First Name:|16
7|(M0040) Patient Last Name|(M0040) Patient Last Name|16
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|16
9|(M0040) Patient Suffix|(M0040) Patient Suffix|16
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|16
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|16
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|16
13|(M0064) Social Security Number:|(M0064) Social Security Number:|16
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|16
15|(M0066) Birth Date:|(M0066) Birth Date:|16
16|(M0069) Gender:|(M0069) Gender:|16
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|16
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|16
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|16
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|16
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|16
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|16
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|16
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|16
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|16
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|16
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|16
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|16
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|16
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|16
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|16
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|16
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|16
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|16
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|16
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|16
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|16
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|16
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|16
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|16
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|16
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|16
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|16
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|16
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|16
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|16
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|16
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|16
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|16
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|16
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|16
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|16
53|(M0300) Current Residence:|(M0300) Current Residence:|16
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|16
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|16
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|16
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|16
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|16
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|16
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|16
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|16
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|16
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|16
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|16
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|16
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|16
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|16
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|16
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|16
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|16
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|16
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|16
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|16
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|16
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|16
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|16
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|16
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|16
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|16
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|16
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|16
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|16
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|16
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|16
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|16
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|16
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|16
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|16
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|16
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|16
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|16
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|16
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|16
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|16
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|16
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|16
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|16
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|16
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|16
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|16
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|16
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|16
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|16
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|16
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|16
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|16
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|16
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|16
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|16
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|16
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|16
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|16
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|16
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|16
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|16
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|16
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|16
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|16
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|16
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|16
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|16
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|16
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|16
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|16
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|16
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|16
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|16
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|16
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|16
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|16
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|16
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|16
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|16
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|16
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|16
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|16
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|16
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|16
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|16
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|16
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|16
144|Wound Care|Wound Care|16
145|Great presidential Moments|Great presidential Moments|16
147|(M0110) Episode Timing|(M0110) Episode Timing|16
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|16
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|16
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|16
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|16
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|16
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|16
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|16
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|16
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|16
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|16
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|16
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|16
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|16
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|16
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|17
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|17
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|17
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|17
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|17
6|(M0040) Patient First Name:|(M0040) Patient First Name:|17
7|(M0040) Patient Last Name|(M0040) Patient Last Name|17
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|17
9|(M0040) Patient Suffix|(M0040) Patient Suffix|17
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|17
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|17
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|17
13|(M0064) Social Security Number:|(M0064) Social Security Number:|17
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|17
15|(M0066) Birth Date:|(M0066) Birth Date:|17
16|(M0069) Gender:|(M0069) Gender:|17
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|17
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|17
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|17
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|17
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|17
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|17
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|17
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|17
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|17
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|17
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|17
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|17
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|17
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|17
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|17
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|17
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|17
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|17
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|17
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|17
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|17
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|17
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|17
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|17
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|17
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|17
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|17
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|17
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|17
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|17
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|17
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|17
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|17
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|17
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|17
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|17
53|(M0300) Current Residence:|(M0300) Current Residence:|17
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|17
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|17
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|17
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|17
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|17
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|17
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|17
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|17
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|17
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|17
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|17
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|17
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|17
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|17
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|17
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|17
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|17
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|17
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|17
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|17
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|17
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|17
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|17
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|17
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|17
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|17
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|17
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|17
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|17
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|17
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|17
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|17
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|17
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|17
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|17
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|17
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|17
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|17
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|17
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|17
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|17
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|17
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|17
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|17
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|17
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|17
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|17
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|17
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|17
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|17
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|17
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|17
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|17
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|17
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|17
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|17
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|17
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|17
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|17
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|17
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|17
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|17
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|17
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|17
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|17
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|17
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|17
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|17
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|17
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|17
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|17
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|17
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|17
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|17
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|17
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|17
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|17
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|17
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|17
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|17
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|17
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|17
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|17
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|17
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|17
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|17
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|17
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|17
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|17
144|Wound Care|Wound Care|17
145|Great presidential Moments|Great presidential Moments|17
147|(M0110) Episode Timing|(M0110) Episode Timing|17
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|17
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|17
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|17
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|17
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|17
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|17
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|17
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|17
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|17
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|17
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|17
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|17
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|17
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|18
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|18
6|(M0040) Patient First Name:|(M0040) Patient First Name:|18
7|(M0040) Patient Last Name|(M0040) Patient Last Name|18
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|18
9|(M0040) Patient Suffix|(M0040) Patient Suffix|18
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|18
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|18
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|18
13|(M0064) Social Security Number:|(M0064) Social Security Number:|18
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|18
15|(M0066) Birth Date:|(M0066) Birth Date:|18
16|(M0069) Gender:|(M0069) Gender:|18
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|18
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|18
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|18
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|18
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|18
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|18
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|18
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|18
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|18
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|18
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|18
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|18
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|18
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|18
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|18
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|18
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|18
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|18
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|18
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|18
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|18
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|18
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|18
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|18
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|18
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|18
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|18
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|18
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|18
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|18
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|18
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|18
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|18
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|18
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|18
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|18
53|(M0300) Current Residence:|(M0300) Current Residence:|18
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|18
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|18
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|18
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|18
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|18
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|18
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|18
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|18
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|18
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|18
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|18
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|18
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|18
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|18
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|18
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|18
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|18
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|18
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|18
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|18
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|18
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|18
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|18
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|18
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|18
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|18
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|18
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|18
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|18
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|18
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|18
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|18
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|18
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|18
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|18
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|18
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|18
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|18
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|18
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|18
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|18
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|18
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|18
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|18
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|18
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|18
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|18
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|18
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|18
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|18
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|18
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|18
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|18
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|18
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|18
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|18
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|18
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|18
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|18
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|18
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|18
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|18
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|18
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|18
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|18
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|18
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|18
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|18
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|18
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|18
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|18
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|18
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|18
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|18
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|18
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|18
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|18
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|18
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|18
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|18
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|18
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|18
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|18
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|18
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|18
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|18
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|18
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|18
144|Wound Care|Wound Care|18
145|Great presidential Moments|Great presidential Moments|18
147|(M0110) Episode Timing|(M0110) Episode Timing|18
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|18
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|18
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|18
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|18
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|18
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|18
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|18
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|18
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|18
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|18
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|18
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|18
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|18
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|18
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|18
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|18
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|18
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|19
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|19
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|19
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|19
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|19
6|(M0040) Patient First Name:|(M0040) Patient First Name:|19
7|(M0040) Patient Last Name|(M0040) Patient Last Name|19
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|19
9|(M0040) Patient Suffix|(M0040) Patient Suffix|19
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|19
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|19
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|19
13|(M0064) Social Security Number:|(M0064) Social Security Number:|19
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|19
15|(M0066) Birth Date:|(M0066) Birth Date:|19
16|(M0069) Gender:|(M0069) Gender:|19
17|(M0072) Primary Referring Physician ID:|(M0072) Primary Referring Physician ID:|19
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|19
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|19
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|19
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|19
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|19
23|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST 14 DAYS? (Mark all that apply.)|(M0175) From which of the following Inpatient Facilities was the patient discharged DURING THE PAST|19
24|(M0180) Inpatient Discharge Date (most recent):|(M0180) Inpatient Discharge Date (most recent):|19
25|(M0190) a. Inpatient Facility ICD1|(M0190) a. Inpatient Facility ICD1|19
26|(M0190) b. Inpatient Facility ICD2|(M0190) b. Inpatient Facility ICD2|19
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|19
28|(M0210) a. Changed Medical Regimen ICD1|(M0210) a. Changed Medical Regimen ICD1|19
29|(M0210) b. Changed Medical Regimen ICD2|(M0210) b. Changed Medical Regimen ICD2|19
30|(M0210) c. Changed Medical Regimen ICD3|(M0210) c. Changed Medical Regimen ICD3|19
31|(M0210) d. Changed Medical Regimen ICD4|(M0210) d. Changed Medical Regimen ICD4|19
32|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced a change in medical or treatment regimen within the past 14 days,  indicate any conditions which existed PRIOR TO the change in medical or treatment regimen.  (Mark all that apply.)|(M0220) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|19
33|(M0230) a. Primary Diagnosis:  ICD Code|(M0230) a. Primary Diagnosis:  ICD Code|19
34|(M0230) a. Primary Diagnosis:  Severity Rating|(M0230) a. Primary Diagnosis:  Severity Rating|19
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|19
36|(M0240) b. Other Diagnosis:  ICD Code|(M0240) b. Other Diagnosis:  ICD Code|19
37|(M0240) b. Other Diagnosis:  Severity Rating|(M0240) b. Other Diagnosis:  Severity Rating|19
38|(M0240) c. Other Diagnosis:  ICD Code|(M0240) c. Other Diagnosis:  ICD Code|19
39|(M0240) c. Other Diagnosis:  Severity Rating|(M0240) c. Other Diagnosis:  Severity Rating|19
40|(M0240) d. Other Diagnosis:  ICD Code|(M0240) d. Other Diagnosis:  ICD Code|19
41|(M0240) d. Other Diagnosis:  Severity Rating|(M0240) d. Other Diagnosis:  Severity Rating|19
42|(M0240) e. Other Diagnosis:  ICD Code|(M0240) e. Other Diagnosis:  ICD Code|19
43|(M0240) e. Other Diagnosis:  Severity Rating|(M0240) e. Other Diagnosis:  Severity Rating|19
44|(M0240) f. Other Diagnosis:  ICD Code|(M0240) f. Other Diagnosis:  ICD Code|19
45|(M0240) f. Other Diagnosis:  Severity Rating|(M0240) f. Other Diagnosis:  Severity Rating|19
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|19
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|19
48|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M0250) Therapies the patient receives AT HOME:  (Mark all that apply.)|19
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|19
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|19
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|19
52|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|(M0290) High Risk Factors characterizing this patient:  (Mark all that apply.)|19
53|(M0300) Current Residence:|(M0300) Current Residence:|19
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|19
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|19
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|19
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|19
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|19
59|(M0390) Vision with corrective lenses if the patient usually wears them:|(M0390) Vision with corrective lenses if the patient usually wears them:|19
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|19
61|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M0410) Speech and Oral (Verbal) Expression of Language (in patient's own language):|19
62|(M0420) Frequency of Pain interfering with the patient's activity or movement:|(M0420) Frequency of Pain interfering with the patient's activity or movement:|19
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|19
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|19
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|19
66|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In darker-pigmented skin, warmth, edema, hardness, or discolored skin may be indicators.|(M0450a) Stage 1:  Nonblanchable erythema of intact skin; the heralding of skin ulceration.  In dark|19
67|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.|(M0450b) Stage 2:  Partial thickness skin loss involving epidermis and/or dermis.  The ulcer is supe|19
68|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.|(M0450c) Stage 3:  Full-thickness skin loss involving damage or necrosis of subcutaneous tissue whic|19
69|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule, etc.).|(M0450d)  Stage 4:  Full-thickness skin loss with extensive destruction, tissue necrosis, or damage|19
70|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due to the presence of eschar or a nonremovable dressing, including  casts?|(M0450e) In addition to the above, is there at least one pressure ulcer that cannot be observed due|19
71|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:|19
72|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|(M0464) Status of Most Problematic (Observable) Pressure Ulcer:|19
73|(M0468) Does this patient have a Stasis Ulcer?|(M0468) Does this patient have a Stasis Ulcer?|19
74|(M0470) Current Number of Observable Stasis Ulcer(s):|(M0470) Current Number of Observable Stasis Ulcer(s):|19
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|19
76|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|(M0476) Status of Most Problematic (Observable) Stasis Ulcer:|19
77|(M0482) Does this patient have a Surgical Wound?|(M0482) Does this patient have a Surgical Wound?|19
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|19
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|19
80|(M0488) Status of Most Problematic (Observable) Surgical Wound:|(M0488) Status of Most Problematic (Observable) Surgical Wound:|19
81|(M0490) When is the patient dyspneic or noticeably Short of Breath?|(M0490) When is the patient dyspneic or noticeably Short of Breath?|19
82|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M0500) Respiratory Treatments utilized at home:  (Mark all that apply.)|19
83|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M0510) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|19
84|(M0520) Urinary Incontinence or Urinary Catheter Presence:|(M0520) Urinary Incontinence or Urinary Catheter Presence:|19
85|(M0530) When does Urinary Incontinence occur?|(M0530) When does Urinary Incontinence occur?|19
86|(M0540) Bowel Incontinence Frequency:|(M0540) Bowel Incontinence Frequency:|19
87|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M0550) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|19
88|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.)|(M0560) Cognitive Functioning:  (Patient's current level of alertness, orientation, comprehension, c|19
89|(M0570) When Confused (Reported or observed):|(M0570) When Confused (Reported or observed):|19
90|(M0580) When Anxious (Reported or Observed):|(M0580) When Anxious (Reported or Observed):|19
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|19
92|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M0610) Behaviors Demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|19
93|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse, verbal disruption, physical aggression, etc.):|(M0620) Frequency of Behavior Problems (Reported or Observed) (e.g., wandering episodes, self abuse,|19
94|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M0630) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|19
95|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Current - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands|19
96|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M0640) Prior - Grooming:  Ability to tend to personal hygiene needs (i.e., washing face and hands,|19
97|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Current - Ability to Dress UPPER Body (with or without dressing aids) including undergarment|19
98|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M0650) Prior - Ability to Dress UPPER Body (with or without dressing aids) including undergarments,|19
99|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Current - Ability to Dress LOWER Body (with or without dressing aids) including undergarment|19
100|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M0660) Prior - Ability to Dress LOWER Body (with or without dressing aids) including undergarments,|19
101|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Current - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands|19
102|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands only).|(M0670) Prior - Bathing:  Ability to wash entire body.  EXCLUDES grooming (washing face and hands on|19
103|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Current - Toileting:  Ability to get to and from the toilet or bedside commode.|19
104|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|(M0680) Prior - Toileting:  Ability to get to and from the toilet or bedside commode.|19
105|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Current - Transferring:  Ability to move from bed to chair, on and off toilet or commode, in|19
106|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into and out of tub or shower, and ability to turn and position self in bed if patient is bedfast.|(M0690) Prior - Transferring:  Ability to move from bed to chair, on and off toilet or commode, into|19
107|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Current - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or us|19
108|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.|(M0700) Prior - Ambulation/Locomotion:  Ability to SAFELY walk, once in a standing position, or use|19
109|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Current - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers onl|19
110|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M0710) Prior - Feeding or Eating:  Ability to feed self meals and snacks.  Note:  This refers only|19
111|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Current - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered me|19
112|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meals:|(M0720) Prior - Planning and Preparing Light Meals (e.g., cereal, sandwich) or reheat delivered meal|19
113|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Current - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public|19
114|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public transportation (bus, train, subway).|(M0730) Prior - Transportation:  Physical and mental ability to SAFELY use a car, taxi, or public tr|19
115|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Current - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machin|19
116|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine, to use washer and dryer, to wash small items by hand.|(M0740) Prior - Laundry:  Ability to do own laundry -- to carry laundry to and from washing machine,|19
117|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Current - Housekeeping:  Ability to safely and effectively perform light housekeeping and he|19
118|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heavier cleaning tasks.|(M0750) Prior - Housekeeping:  Ability to safely and effectively perform light housekeeping and heav|19
119|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery):|(M0760) Current - Shopping:  Ability to plan for, select, and purchase items in a store and to carry|19
120|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry them home or arrange delivery) :|(M0760) Prior - Shopping:  Ability to plan for, select, and purchase items in a store and to carry t|19
121|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Current - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIV|19
122|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVELY use the telephone to communicate.|(M0770) Prior - Ability to Use Telephone:  Ability to answer the phone, dial numbers, and EFFECTIVEL|19
123|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Current - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescri|19
124|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M0780) Prior - Management of Oral Medications:  PATIENT'S ABILITY to prepare and take ALL prescribe|19
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|19
126|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Prior - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL|19
127|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M0800) Current - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pr|19
128|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. EXCLUDES IV medications:|(M0800) Prior - Management of Injectable Medications: PATIENT'S ABILITY to prepare and take ALL pres|19
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|19
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|19
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|19
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|19
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|19
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|19
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|19
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|19
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|19
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|19
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|19
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|19
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|19
144|Wound Care|Wound Care|19
145|Great presidential Moments|Great presidential Moments|19
147|(M0110) Episode Timing|(M0110) Episode Timing|19
148|(M0826) Therapy Need Number|(M0826) Therapy Need Number|19
149|(M0826) Therapy Need Not Applicable|(M0826) Therapy Need Not Applicable|19
150|(M0246A3) Case Mix Diagnosis: Primary, Column 3|(M0246A3) Case Mix Diagnosis: Primary, Column 3|19
151|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|(M0246B3) Case Mix Diagnosis: First Secondary, Column 3|19
152|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|(M0246C3) Case Mix Diagnosis: Second Secondary, Column 3|19
153|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|(M0246D3) Case Mix Diagnosis:Third Secondary, Column 3|19
154|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|(M0246E3) Case Mix Diagnosis: Fourth Secondary, Column 3|19
155|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|(M0246F3) Case Mix Diagnosis: Fifth Secondary, Column 3|19
156|(M0246A4) Case Mix Diagnosis: Primary Column 4|(M0246A4) Case Mix Diagnosis: Primary Column 4|19
157|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|(M0246B4) Case Mix Diagnosis: First Secondary, Column 4|19
158|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|(M0246C4) Case Mix Diagnosis: Second Secondary, Column 4|19
159|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|(M0246D4) Case Mix Diagnosis: Third Secondary, Column 4|19
160|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|(M0246E4) Case Mix Diagnosis: Fouth Secondary, Column 4|19
161|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|(M0246F4) Case Mix Diagnosis: Fifth Secondary, Column 4|19
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|21
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|21
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|21
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|21
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|21
6|(M0040) Patient First Name:|(M0040) Patient First Name:|21
7|(M0040) Patient Last Name|(M0040) Patient Last Name|21
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|21
9|(M0040) Patient Suffix|(M0040) Patient Suffix|21
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|21
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|21
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|21
13|(M0064) Social Security Number:|(M0064) Social Security Number:|21
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|21
15|(M0066) Birth Date:|(M0066) Birth Date:|21
16|(M0069) Gender:|(M0069) Gender:|21
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|21
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|21
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|21
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|21
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|21
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|21
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|21
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|21
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|21
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|21
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|21
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|21
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|21
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|21
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|21
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|21
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|21
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|21
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|21
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|21
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|21
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|21
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|21
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|21
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|21
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|21
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|21
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|21
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|21
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|21
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|21
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|21
53|(M0300) Current Residence:|(M0300) Current Residence:|21
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|21
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|21
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|21
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|21
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|21
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|21
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|21
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|21
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|21
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|21
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|21
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|21
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|21
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|21
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|21
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device:|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|21
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|21
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|21
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|21
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|21
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|21
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|21
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|21
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|21
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|21
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|21
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|21
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|21
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|21
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|21
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|21
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|21
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|21
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|21
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|21
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|21
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|21
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|21
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|21
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|21
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|21
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|21
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|21
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|21
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|21
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|21
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|21
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|21
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|21
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|21
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|21
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|21
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|21
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|21
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|21
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|21
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|21
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|21
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|21
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|21
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|21
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|21
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|21
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|21
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|21
144|Wound Care|Wound Care|21
145|Great presidential Moments|Great presidential Moments|21
147|(M0110) Episode Timing|(M0110) Episode Timing|21
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|21
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|21
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|21
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|21
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|21
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|21
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|21
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|21
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|21
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|21
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|21
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|21
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|21
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|21
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|21
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|21
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|21
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|21
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|21
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|21
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|21
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|21
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|21
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|21
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|21
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|21
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|21
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|21
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|21
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|21
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|21
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|21
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|21
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|21
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|21
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|21
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|21
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|21
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|21
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|21
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|21
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|21
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|21
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|21
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|21
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|21
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|21
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|21
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|21
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|21
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|21
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|21
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|21
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|21
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|21
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|21
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|21
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|21
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|21
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|21
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|21
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|21
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|21
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|21
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|21
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|21
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|21
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|21
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|21
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|21
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|21
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|21
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|21
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|21
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|21
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|21
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|21
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|21
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|21
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|21
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|21
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|21
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|21
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|21
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|21
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|21
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|21
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|21
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|21
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|21
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|21
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|23
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|23
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|23
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|23
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|23
6|(M0040) Patient First Name:|(M0040) Patient First Name:|23
7|(M0040) Patient Last Name|(M0040) Patient Last Name|23
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|23
9|(M0040) Patient Suffix|(M0040) Patient Suffix|23
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|23
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|23
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|23
13|(M0064) Social Security Number:|(M0064) Social Security Number:|23
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|23
15|(M0066) Birth Date:|(M0066) Birth Date:|23
16|(M0069) Gender:|(M0069) Gender:|23
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|23
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|23
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|23
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|23
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|23
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|23
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|23
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|23
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|23
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|23
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|23
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|23
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|23
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|23
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|23
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|23
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|23
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|23
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|23
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|23
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|23
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|23
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|23
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|23
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|23
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|23
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|23
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|23
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|23
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|23
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|23
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|23
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|23
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|23
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|23
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|23
53|(M0300) Current Residence:|(M0300) Current Residence:|23
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|23
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|23
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|23
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|23
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|23
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|23
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|23
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|23
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|23
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|23
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|23
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|23
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|23
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|23
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|23
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none):  Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|23
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|23
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|23
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|23
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|23
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|23
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|23
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|23
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|23
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|23
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|23
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|23
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|23
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|23
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|23
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|23
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|23
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|23
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|23
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|23
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|23
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|23
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|23
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|23
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|23
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|23
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|23
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|23
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|23
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|23
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|23
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|23
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|23
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|23
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|23
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|23
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|23
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|23
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|23
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|23
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|23
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|23
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|23
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|23
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|23
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|23
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|23
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|23
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|23
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|23
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|23
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|23
144|Wound Care|Wound Care|23
145|Great presidential Moments|Great presidential Moments|23
147|(M0110) Episode Timing|(M0110) Episode Timing|23
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|23
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|23
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|23
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|23
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|23
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|23
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|23
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|23
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|23
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|23
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|23
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|23
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|23
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|23
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|23
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|23
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|23
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|23
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|23
169|(M1010) d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|23
170|(M1010) e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|23
171|(M1010) f. Inpatient Facility ICD6|(M1010) f. Inpatient Facility ICD6|23
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|23
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|23
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|23
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|23
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|23
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|23
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|23
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|23
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|23
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|23
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|23
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|23
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|23
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|23
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|23
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|23
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|23
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|23
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|23
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|23
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|23
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|23
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|23
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|23
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|23
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|23
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|23
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|23
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|23
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|23
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|23
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|23
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|23
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|23
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|23
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|23
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|23
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|23
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|23
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|23
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|23
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|23
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|23
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|23
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|23
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|23
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|23
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|23
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|23
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|23
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|23
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|23
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|23
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|23
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|23
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|23
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|23
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|23
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|23
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|23
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|23
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|23
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|24
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|24
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|24
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|24
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|24
6|(M0040) Patient First Name:|(M0040) Patient First Name:|24
7|(M0040) Patient Last Name|(M0040) Patient Last Name|24
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|24
9|(M0040) Patient Suffix|(M0040) Patient Suffix|24
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|24
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|24
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|24
13|(M0064) Social Security Number:|(M0064) Social Security Number:|24
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|24
15|(M0066) Birth Date:|(M0066) Birth Date:|24
16|(M0069) Gender:|(M0069) Gender:|24
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|24
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|24
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|24
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|24
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|24
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|24
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|24
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|24
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|24
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|24
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|24
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|24
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|24
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|24
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|24
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|24
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|24
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|24
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|24
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|24
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|24
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|24
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|24
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|24
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|24
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|24
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|24
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|24
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|24
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|24
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|24
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|24
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|24
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|24
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|24
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|24
53|(M0300) Current Residence:|(M0300) Current Residence:|24
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|24
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|24
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|24
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|24
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|24
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|24
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|24
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|24
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|24
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|24
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|24
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|24
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|24
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|24
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|24
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|24
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|24
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|24
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|24
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|24
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|24
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|24
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|24
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|24
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|24
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|24
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|24
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|24
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|24
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|24
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|24
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|24
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|24
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|24
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|24
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|24
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|24
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|24
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|24
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|24
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|24
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|24
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|24
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|24
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|24
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|24
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|24
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|24
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|24
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|24
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|24
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|24
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|24
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|24
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|24
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|24
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|24
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|24
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|24
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|24
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|24
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|24
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|24
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|24
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|24
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|24
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|24
144|Wound Care|Wound Care|24
145|Great presidential Moments|Great presidential Moments|24
147|(M0110) Episode Timing|(M0110) Episode Timing|24
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|24
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|24
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|24
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|24
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|24
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|24
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|24
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|24
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|24
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|24
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|24
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|24
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|24
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|24
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|24
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|24
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|24
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|24
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|24
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|24
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|24
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|24
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|24
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|24
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|24
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|24
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|24
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|24
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|24
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|24
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|24
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|24
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|24
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|24
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|24
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|24
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|24
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|24
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|24
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|24
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|24
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|24
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|24
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|24
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|24
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|24
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|24
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|24
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|24
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|24
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|24
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|24
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|24
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|24
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|24
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|24
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|24
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|24
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|24
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|24
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|24
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|24
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|24
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|24
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|24
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|24
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|24
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|24
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|24
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|24
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|24
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|24
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|24
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|24
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|24
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|24
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|24
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|24
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|24
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|24
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|24
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|24
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|24
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|24
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|24
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|24
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|24
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|24
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|25
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|25
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|25
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|25
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|25
6|(M0040) Patient First Name:|(M0040) Patient First Name:|25
7|(M0040) Patient Last Name|(M0040) Patient Last Name|25
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|25
9|(M0040) Patient Suffix|(M0040) Patient Suffix|25
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|25
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|25
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|25
13|(M0064) Social Security Number:|(M0064) Social Security Number:|25
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|25
15|(M0066) Birth Date:|(M0066) Birth Date:|25
16|(M0069) Gender:|(M0069) Gender:|25
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|25
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|25
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|25
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|25
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|25
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|25
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|25
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|25
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|25
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|25
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|25
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|25
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|25
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|25
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|25
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|25
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|25
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|25
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|25
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|25
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|25
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|25
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|25
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|25
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|25
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|25
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|25
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|25
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|25
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|25
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|25
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|25
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|25
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|25
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|25
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|25
53|(M0300) Current Residence:|(M0300) Current Residence:|25
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|25
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|25
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|25
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|25
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|25
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|25
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|25
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|25
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|25
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|25
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|25
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|25
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|25
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|25
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|25
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|25
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|25
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|25
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|25
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|25
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|25
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|25
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|25
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|25
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|25
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|25
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|25
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|25
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|25
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|25
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|25
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|25
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|25
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|25
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|25
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|25
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|25
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|25
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|25
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|25
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|25
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|25
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|25
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|25
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|25
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|25
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|25
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|25
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|25
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|25
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|25
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|25
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|25
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|25
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|25
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|25
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|25
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|25
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|25
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|25
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|25
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|25
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|25
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|25
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|25
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|25
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|25
144|Wound Care|Wound Care|25
145|Great presidential Moments|Great presidential Moments|25
147|(M0110) Episode Timing|(M0110) Episode Timing|25
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|25
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|25
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|25
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|25
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|25
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|25
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|25
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|25
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|25
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|25
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|25
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|25
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|25
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|25
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|25
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|25
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|25
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|25
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|25
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|25
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|25
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|25
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|25
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|25
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|25
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|25
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|25
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|25
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|25
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|25
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|25
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|25
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|25
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|25
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|25
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|25
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|25
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|25
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|25
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|25
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|25
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|25
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|25
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|25
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|25
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|25
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|25
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|25
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|25
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|25
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|25
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|25
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|25
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|25
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|25
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|25
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|25
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|25
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|25
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|25
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|25
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|25
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|25
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|25
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|25
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|25
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|25
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|25
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|25
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|25
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|25
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|25
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|25
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|25
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|25
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|25
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|25
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|25
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|25
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|25
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|25
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|25
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|25
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|25
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|25
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|25
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|25
259|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|25
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|26
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|26
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|26
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|26
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|26
6|(M0040) Patient First Name:|(M0040) Patient First Name:|26
7|(M0040) Patient Last Name|(M0040) Patient Last Name|26
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|26
9|(M0040) Patient Suffix|(M0040) Patient Suffix|26
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|26
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|26
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|26
13|(M0064) Social Security Number:|(M0064) Social Security Number:|26
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|26
15|(M0066) Birth Date:|(M0066) Birth Date:|26
16|(M0069) Gender:|(M0069) Gender:|26
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|26
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|26
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|26
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|26
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|26
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|26
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|26
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|26
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|26
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|26
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|26
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|26
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|26
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|26
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|26
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|26
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|26
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|26
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|26
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|26
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|26
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|26
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|26
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|26
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|26
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|26
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|26
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|26
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|26
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|26
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|26
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|26
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|26
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|26
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|26
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|26
53|(M0300) Current Residence:|(M0300) Current Residence:|26
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|26
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|26
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|26
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|26
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|26
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|26
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|26
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|26
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|26
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|26
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|26
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|26
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|26
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|26
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|26
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|26
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|26
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|26
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|26
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|26
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|26
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|26
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|26
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|26
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|26
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|26
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|26
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|26
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|26
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|26
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|26
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|26
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|26
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|26
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|26
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|26
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|26
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|26
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|26
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|26
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|26
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|26
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|26
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|26
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|26
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|26
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|26
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|26
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|26
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|26
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|26
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|26
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|26
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|26
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|26
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|26
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|26
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|26
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|26
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|26
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|26
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|26
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|26
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|26
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|26
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|26
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|26
144|Wound Care|Wound Care|26
145|Great presidential Moments|Great presidential Moments|26
147|(M0110) Episode Timing|(M0110) Episode Timing|26
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|26
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|26
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|26
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|26
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|26
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|26
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|26
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|26
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|26
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|26
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|26
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|26
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|26
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|26
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|26
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|26
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|26
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|26
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|26
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|26
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|26
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|26
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|26
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|26
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|26
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|26
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|26
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|26
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|26
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|26
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|26
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|26
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|26
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|26
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|26
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|26
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|26
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|26
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|26
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|26
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|26
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|26
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|26
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|26
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|26
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|26
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|26
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|26
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|26
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|26
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|26
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|26
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|26
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|26
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|26
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|26
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|26
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|26
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|26
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|26
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|26
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|26
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|26
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|26
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|26
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|26
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|26
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|26
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|26
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|26
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|26
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|26
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|26
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|26
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|26
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|26
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|26
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|26
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|26
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|26
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|26
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|26
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|26
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|26
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|26
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|26
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|26
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|26
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|26
241|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|26
242|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|26
243|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|26
244|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|26
245|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|26
246|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|26
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|27
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|27
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|27
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|27
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|27
6|(M0040) Patient First Name:|(M0040) Patient First Name:|27
7|(M0040) Patient Last Name|(M0040) Patient Last Name|27
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|27
9|(M0040) Patient Suffix|(M0040) Patient Suffix|27
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|27
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|27
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|27
13|(M0064) Social Security Number:|(M0064) Social Security Number:|27
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|27
15|(M0066) Birth Date:|(M0066) Birth Date:|27
16|(M0069) Gender:|(M0069) Gender:|27
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|27
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|27
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|27
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|27
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|27
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|27
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|27
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|27
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|27
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|27
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|27
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|27
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|27
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|27
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|27
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|27
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|27
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|27
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|27
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|27
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|27
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|27
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|27
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|27
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|27
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|27
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|27
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|27
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|27
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|27
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|27
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|27
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|27
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|27
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|27
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|27
53|(M0300) Current Residence:|(M0300) Current Residence:|27
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|27
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|27
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|27
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|27
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|27
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|27
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|27
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|27
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|27
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|27
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|27
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|27
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|27
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|27
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|27
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|27
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|27
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|27
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|27
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|27
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|27
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|27
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|27
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|27
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|27
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|27
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|27
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|27
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|27
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|27
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|27
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|27
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|27
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|27
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|27
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|27
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|27
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|27
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|27
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|27
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|27
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|27
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|27
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|27
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|27
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|27
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|27
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|27
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|27
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|27
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|27
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|27
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|27
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|27
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|27
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|27
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|27
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|27
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|27
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|27
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|27
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|27
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|27
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|27
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|27
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|27
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|27
144|Wound Care|Wound Care|27
145|Great presidential Moments|Great presidential Moments|27
147|(M0110) Episode Timing|(M0110) Episode Timing|27
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|27
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|27
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|27
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|27
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|27
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|27
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|27
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|27
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|27
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|27
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|27
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|27
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|27
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|27
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|27
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|27
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|27
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|27
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|27
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|27
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|27
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|27
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|27
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|27
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|27
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|27
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|27
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|27
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|27
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|27
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|27
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|27
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|27
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|27
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|27
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|27
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|27
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|27
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|27
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|27
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|27
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|27
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|27
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|27
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|27
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|27
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|27
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|27
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|27
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|27
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|27
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|27
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|27
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|27
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|27
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|27
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|27
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|27
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|27
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|27
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|27
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|27
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|27
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|27
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|27
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|27
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|27
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|27
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|27
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|27
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|27
251|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|27
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|27
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|27
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|27
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|27
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|27
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|27
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|27
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|27
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|27
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|27
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|27
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|27
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|27
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|27
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|27
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|27
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|27
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|27
247|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|27
248|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|27
249|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|27
250|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|27
252|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|27
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|28
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|28
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|28
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|28
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|28
6|(M0040) Patient First Name:|(M0040) Patient First Name:|28
7|(M0040) Patient Last Name|(M0040) Patient Last Name|28
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|28
9|(M0040) Patient Suffix|(M0040) Patient Suffix|28
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|28
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|28
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|28
13|(M0064) Social Security Number:|(M0064) Social Security Number:|28
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|28
15|(M0066) Birth Date:|(M0066) Birth Date:|28
16|(M0069) Gender:|(M0069) Gender:|28
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|28
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|28
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|28
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|28
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|28
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|28
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|28
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|28
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|28
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|28
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|28
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|28
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|28
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|28
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|28
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|28
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|28
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|28
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|28
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|28
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|28
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|28
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|28
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|28
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|28
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|28
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|28
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|28
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|28
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|28
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|28
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|28
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|28
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|28
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|28
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|28
53|(M0300) Current Residence:|(M0300) Current Residence:|28
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|28
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|28
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|28
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|28
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|28
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|28
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|28
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|28
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|28
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|28
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|28
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|28
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|28
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|28
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|28
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|28
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|28
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|28
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|28
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|28
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|28
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|28
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|28
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|28
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|28
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|28
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|28
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|28
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|28
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|28
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|28
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|28
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|28
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|28
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|28
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|28
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|28
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|28
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|28
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|28
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|28
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|28
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|28
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|28
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|28
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|28
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|28
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|28
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|28
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|28
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|28
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|28
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|28
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|28
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|28
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|28
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|28
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|28
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|28
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|28
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|28
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|28
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|28
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|28
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|28
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|28
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|28
144|Wound Care|Wound Care|28
145|Great presidential Moments|Great presidential Moments|28
147|(M0110) Episode Timing|(M0110) Episode Timing|28
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|28
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|28
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|28
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|28
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|28
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|28
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|28
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|28
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|28
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|28
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|28
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|28
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|28
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|28
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|28
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|28
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|28
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|28
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|28
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|28
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|28
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|28
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|28
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|28
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|28
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|28
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|28
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|28
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|28
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|28
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|28
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|28
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|28
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|28
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|28
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|28
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|28
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|28
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|28
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|28
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|28
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|28
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|28
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|28
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|28
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|28
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|28
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|28
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|28
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|28
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|28
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|28
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|28
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|28
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|28
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|28
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|28
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|28
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|28
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|28
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|28
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|28
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|28
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|28
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|28
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|28
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|28
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|28
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|28
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|28
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|28
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|28
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|28
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|28
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|28
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|28
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|28
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|28
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|28
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|28
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|28
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|28
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|28
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|28
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|28
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|28
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|28
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|28
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|28
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|29
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|29
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|29
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|29
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|29
6|(M0040) Patient First Name:|(M0040) Patient First Name:|29
7|(M0040) Patient Last Name|(M0040) Patient Last Name|29
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|29
9|(M0040) Patient Suffix|(M0040) Patient Suffix|29
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|29
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|29
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|29
13|(M0064) Social Security Number:|(M0064) Social Security Number:|29
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|29
15|(M0066) Birth Date:|(M0066) Birth Date:|29
16|(M0069) Gender:|(M0069) Gender:|29
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|29
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|29
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|29
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|29
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|29
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|29
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|29
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|29
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|29
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|29
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|29
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|29
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|29
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|29
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|29
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|29
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|29
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|29
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|29
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|29
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|29
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|29
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|29
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|29
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|29
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|29
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|29
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|29
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|29
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|29
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|29
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|29
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|29
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|29
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|29
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|29
53|(M0300) Current Residence:|(M0300) Current Residence:|29
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|29
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|29
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|29
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|29
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|29
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|29
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|29
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|29
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|29
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|29
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|29
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|29
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|29
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|29
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|29
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|29
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|29
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|29
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|29
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|29
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|29
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|29
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|29
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|29
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|29
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|29
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|29
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|29
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|29
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|29
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|29
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|29
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|29
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|29
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|29
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|29
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|29
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|29
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|29
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|29
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|29
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|29
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|29
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|29
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|29
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|29
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|29
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|29
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|29
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|29
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|29
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|29
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|29
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|29
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|29
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|29
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|29
132|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|29
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|29
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|29
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0903 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|29
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|29
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|29
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|29
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|29
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|29
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|29
144|Wound Care|Wound Care|29
145|Great presidential Moments|Great presidential Moments|29
147|(M0110) Episode Timing|(M0110) Episode Timing|29
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|29
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|29
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|29
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|29
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|29
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|29
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|29
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|29
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|29
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|29
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|29
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|29
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|29
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|29
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|29
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|29
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|29
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|29
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|29
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|29
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|29
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|29
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|29
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|29
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|29
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|29
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|29
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|29
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|29
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|29
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|29
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|29
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|29
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|29
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|29
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|29
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|29
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|29
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|29
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|29
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|29
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|29
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|29
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|29
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|29
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|29
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|29
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|29
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|29
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|29
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|29
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|29
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|29
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|29
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|29
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|29
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|29
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|29
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|29
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|29
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|29
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|29
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|29
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|29
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|29
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|29
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|29
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|29
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|29
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|29
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|29
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|29
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|29
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|29
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|29
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|29
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|29
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|29
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|29
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|29
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|29
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|29
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|29
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|29
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|29
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|29
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|29
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|29
253|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|29
254|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|29
255|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|29
256|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|29
257|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|29
258|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|29
263|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|29
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|31
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|31
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|31
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|31
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|31
6|(M0040) Patient First Name:|(M0040) Patient First Name:|31
7|(M0040) Patient Last Name|(M0040) Patient Last Name|31
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|31
9|(M0040) Patient Suffix|(M0040) Patient Suffix|31
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|31
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|31
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|31
13|(M0064) Social Security Number:|(M0064) Social Security Number:|31
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|31
15|(M0066) Birth Date:|(M0066) Birth Date:|31
16|(M0069) Gender:|(M0069) Gender:|31
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|31
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|31
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|31
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|31
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|31
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|31
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|31
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|31
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|31
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|31
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|31
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|31
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|31
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|31
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|31
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|31
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|31
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|31
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|31
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|31
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|31
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|31
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|31
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|31
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|31
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|31
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|31
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|31
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|31
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|31
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|31
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|31
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|31
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|31
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|31
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|31
53|(M0300) Current Residence:|(M0300) Current Residence:|31
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|31
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|31
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|31
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|31
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|31
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|31
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|31
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|31
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|31
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|31
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|31
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|31
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|31
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|31
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|31
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device:|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|31
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|31
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|31
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|31
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|31
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|31
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|31
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|31
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|31
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|31
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|31
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|31
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|31
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|31
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|31
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|31
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|31
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|31
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|31
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|31
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|31
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|31
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|31
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|31
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|31
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|31
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|31
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|31
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|31
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|31
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|31
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|31
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|31
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|31
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|31
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|31
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|31
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|31
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|31
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|31
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|31
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|31
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|31
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|31
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|31
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|31
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|31
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|31
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|31
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|31
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|31
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|31
144|Wound Care|Wound Care|31
145|Great presidential Moments|Great presidential Moments|31
147|(M0110) Episode Timing|(M0110) Episode Timing|31
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|31
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|31
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|31
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|31
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|31
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|31
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|31
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|31
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|31
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|31
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|31
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|31
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|31
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|31
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|31
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|31
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|31
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|31
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|31
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|31
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|31
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|31
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|31
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|31
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|31
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|31
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|31
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|31
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|31
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|31
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|31
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|31
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|31
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|31
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|31
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|31
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|31
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|31
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|31
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|31
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|31
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|31
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|31
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|31
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|31
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|31
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|31
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|31
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|31
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|31
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|31
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|31
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|31
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|31
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|31
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|31
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|31
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|31
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|31
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|31
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|31
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|31
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|31
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|31
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|31
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|31
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|31
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|31
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|31
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|31
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|31
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|31
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|31
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|31
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|31
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|31
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|31
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|31
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|31
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|31
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|31
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|31
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|31
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|31
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|31
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|33
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|33
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|33
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|33
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|33
6|(M0040) Patient First Name:|(M0040) Patient First Name:|33
7|(M0040) Patient Last Name|(M0040) Patient Last Name|33
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|33
9|(M0040) Patient Suffix|(M0040) Patient Suffix|33
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|33
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|33
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|33
13|(M0064) Social Security Number:|(M0064) Social Security Number:|33
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|33
15|(M0066) Birth Date:|(M0066) Birth Date:|33
16|(M0069) Gender:|(M0069) Gender:|33
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|33
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|33
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|33
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|33
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|33
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|33
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|33
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|33
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|33
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|33
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|33
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|33
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|33
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|33
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|33
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|33
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|33
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|33
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|33
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|33
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|33
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|33
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|33
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|33
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|33
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|33
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|33
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|33
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|33
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|33
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|33
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|33
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|33
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|33
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|33
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|33
53|(M0300) Current Residence:|(M0300) Current Residence:|33
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|33
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|33
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|33
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|33
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|33
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|33
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|33
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|33
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|33
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|33
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|33
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|33
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|33
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|33
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|33
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none):  Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|33
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|33
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|33
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|33
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|33
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|33
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|33
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|33
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|33
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|33
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|33
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|33
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|33
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|33
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|33
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|33
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|33
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|33
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|33
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|33
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|33
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|33
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|33
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|33
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|33
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|33
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|33
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|33
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|33
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|33
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|33
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|33
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|33
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|33
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|33
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|33
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|33
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|33
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|33
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|33
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|33
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|33
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|33
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|33
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|33
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|33
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|33
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|33
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|33
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|33
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|33
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|33
144|Wound Care|Wound Care|33
145|Great presidential Moments|Great presidential Moments|33
147|(M0110) Episode Timing|(M0110) Episode Timing|33
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|33
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|33
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|33
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|33
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|33
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|33
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|33
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|33
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|33
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|33
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|33
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|33
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|33
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|33
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|33
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|33
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|33
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|33
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|33
169|(M1010) d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|33
170|(M1010) e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|33
171|(M1010) f. Inpatient Facility ICD6|(M1010) f. Inpatient Facility ICD6|33
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|33
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|33
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|33
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|33
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|33
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|33
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|33
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|33
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|33
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|33
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|33
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|33
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|33
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|33
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|33
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|33
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|33
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|33
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|33
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|33
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|33
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|33
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|33
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|33
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|33
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|33
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|33
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|33
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|33
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|33
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|33
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|33
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|33
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|33
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|33
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|33
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|33
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|33
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|33
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|33
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|33
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|33
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|33
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|33
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|33
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|33
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|33
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|33
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|33
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|33
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|33
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|33
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|33
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|33
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|33
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|33
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|33
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|33
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|33
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|33
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|33
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|33
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|34
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|34
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|34
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|34
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|34
6|(M0040) Patient First Name:|(M0040) Patient First Name:|34
7|(M0040) Patient Last Name|(M0040) Patient Last Name|34
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|34
9|(M0040) Patient Suffix|(M0040) Patient Suffix|34
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|34
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|34
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|34
13|(M0064) Social Security Number:|(M0064) Social Security Number:|34
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|34
15|(M0066) Birth Date:|(M0066) Birth Date:|34
16|(M0069) Gender:|(M0069) Gender:|34
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|34
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|34
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|34
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|34
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|34
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|34
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|34
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|34
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|34
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|34
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|34
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|34
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|34
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|34
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|34
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|34
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|34
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|34
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|34
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|34
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|34
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|34
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|34
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|34
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|34
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|34
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|34
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|34
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|34
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|34
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|34
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|34
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|34
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|34
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|34
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|34
53|(M0300) Current Residence:|(M0300) Current Residence:|34
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|34
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|34
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|34
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|34
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|34
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|34
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|34
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|34
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|34
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|34
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|34
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|34
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|34
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|34
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|34
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|34
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|34
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|34
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|34
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|34
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|34
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|34
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|34
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|34
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|34
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|34
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|34
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|34
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|34
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|34
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|34
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|34
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|34
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|34
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|34
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|34
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|34
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|34
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|34
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|34
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|34
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|34
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|34
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|34
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|34
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|34
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|34
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|34
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|34
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|34
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|34
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|34
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|34
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|34
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|34
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|34
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|34
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|34
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|34
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|34
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|34
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|34
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|34
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|34
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|34
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|34
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|34
144|Wound Care|Wound Care|34
145|Great presidential Moments|Great presidential Moments|34
147|(M0110) Episode Timing|(M0110) Episode Timing|34
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|34
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|34
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|34
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|34
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|34
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|34
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|34
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|34
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|34
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|34
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|34
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|34
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|34
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|34
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|34
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|34
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|34
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|34
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|34
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|34
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|34
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|34
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|34
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|34
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|34
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|34
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|34
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|34
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|34
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|34
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|34
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|34
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|34
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|34
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|34
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|34
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|34
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|34
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|34
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|34
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|34
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|34
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|34
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|34
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|34
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|34
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|34
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|34
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|34
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|34
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|34
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|34
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|34
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|34
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|34
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|34
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|34
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|34
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|34
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|34
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|34
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|34
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|34
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|34
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|34
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|34
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|34
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|34
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|34
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|34
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|34
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|34
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|34
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|34
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|34
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|34
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|34
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|34
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|34
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|34
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|34
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|34
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|34
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|34
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|34
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|34
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|34
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|34
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|35
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|35
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|35
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|35
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|35
6|(M0040) Patient First Name:|(M0040) Patient First Name:|35
7|(M0040) Patient Last Name|(M0040) Patient Last Name|35
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|35
9|(M0040) Patient Suffix|(M0040) Patient Suffix|35
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|35
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|35
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|35
13|(M0064) Social Security Number:|(M0064) Social Security Number:|35
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|35
15|(M0066) Birth Date:|(M0066) Birth Date:|35
16|(M0069) Gender:|(M0069) Gender:|35
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|35
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|35
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|35
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|35
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|35
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|35
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|35
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|35
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|35
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|35
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|35
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|35
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|35
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|35
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|35
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|35
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|35
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|35
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|35
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|35
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|35
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|35
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|35
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|35
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|35
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|35
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|35
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|35
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|35
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|35
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|35
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|35
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|35
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|35
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|35
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|35
53|(M0300) Current Residence:|(M0300) Current Residence:|35
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|35
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|35
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|35
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|35
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|35
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|35
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|35
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|35
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|35
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|35
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|35
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|35
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|35
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|35
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|35
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|35
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|35
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|35
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|35
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|35
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|35
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|35
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|35
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|35
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|35
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|35
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|35
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|35
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|35
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|35
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|35
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|35
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|35
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|35
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|35
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|35
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|35
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|35
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|35
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|35
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|35
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|35
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|35
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|35
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|35
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|35
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|35
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|35
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|35
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|35
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|35
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|35
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|35
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|35
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|35
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|35
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|35
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|35
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|35
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|35
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|35
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|35
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|35
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|35
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|35
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|35
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|35
144|Wound Care|Wound Care|35
145|Great presidential Moments|Great presidential Moments|35
147|(M0110) Episode Timing|(M0110) Episode Timing|35
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|35
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|35
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|35
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|35
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|35
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|35
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|35
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|35
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|35
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|35
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|35
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|35
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|35
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|35
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|35
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|35
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|35
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|35
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|35
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|35
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|35
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|35
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|35
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|35
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|35
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|35
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|35
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|35
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|35
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|35
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|35
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|35
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|35
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|35
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|35
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|35
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|35
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|35
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|35
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|35
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|35
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|35
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|35
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|35
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|35
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|35
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|35
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|35
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|35
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|35
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|35
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|35
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|35
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|35
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|35
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|35
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|35
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|35
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|35
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|35
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|35
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|35
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|35
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|35
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|35
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|35
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|35
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|35
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|35
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|35
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|35
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|35
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|35
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|35
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|35
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|35
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|35
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|35
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|35
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|35
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|35
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|35
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|35
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|35
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|35
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|35
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|35
259|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|35
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|36
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|36
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|36
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|36
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|36
6|(M0040) Patient First Name:|(M0040) Patient First Name:|36
7|(M0040) Patient Last Name|(M0040) Patient Last Name|36
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|36
9|(M0040) Patient Suffix|(M0040) Patient Suffix|36
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|36
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|36
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|36
13|(M0064) Social Security Number:|(M0064) Social Security Number:|36
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|36
15|(M0066) Birth Date:|(M0066) Birth Date:|36
16|(M0069) Gender:|(M0069) Gender:|36
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|36
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|36
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|36
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|36
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|36
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|36
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|36
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|36
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|36
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|36
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|36
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|36
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|36
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|36
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|36
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|36
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|36
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|36
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|36
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|36
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|36
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|36
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|36
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|36
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|36
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|36
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|36
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|36
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|36
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|36
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|36
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|36
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|36
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|36
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|36
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|36
53|(M0300) Current Residence:|(M0300) Current Residence:|36
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|36
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|36
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|36
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|36
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|36
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|36
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|36
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|36
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|36
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|36
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|36
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|36
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|36
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|36
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|36
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|36
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|36
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|36
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|36
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|36
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|36
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|36
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|36
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|36
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|36
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|36
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|36
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|36
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|36
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|36
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|36
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|36
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|36
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|36
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|36
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|36
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|36
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|36
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|36
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|36
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|36
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|36
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|36
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|36
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|36
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|36
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|36
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|36
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|36
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|36
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|36
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|36
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|36
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|36
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|36
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|36
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|36
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|36
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|36
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|36
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|36
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|36
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|36
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|36
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|36
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|36
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|36
144|Wound Care|Wound Care|36
145|Great presidential Moments|Great presidential Moments|36
147|(M0110) Episode Timing|(M0110) Episode Timing|36
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|36
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|36
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|36
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|36
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|36
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|36
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|36
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|36
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|36
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|36
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|36
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|36
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|36
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|36
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|36
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|36
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|36
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|36
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|36
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|36
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|36
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|36
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|36
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|36
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|36
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|36
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|36
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|36
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|36
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|36
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|36
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|36
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|36
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|36
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|36
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|36
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|36
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|36
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|36
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|36
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|36
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|36
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|36
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|36
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|36
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|36
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|36
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|36
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|36
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|36
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|36
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|36
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|36
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|36
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|36
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|36
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|36
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|36
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|36
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|36
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|36
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|36
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|36
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|36
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|36
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|36
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|36
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|36
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|36
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|36
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|36
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|36
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|36
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|36
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|36
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|36
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|36
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|36
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|36
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|36
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|36
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|36
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|36
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|36
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|36
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|36
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|36
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|36
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|36
241|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|36
242|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|36
243|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|36
244|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|36
245|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|36
246|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|36
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|37
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|37
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|37
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|37
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|37
6|(M0040) Patient First Name:|(M0040) Patient First Name:|37
7|(M0040) Patient Last Name|(M0040) Patient Last Name|37
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|37
9|(M0040) Patient Suffix|(M0040) Patient Suffix|37
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|37
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|37
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|37
13|(M0064) Social Security Number:|(M0064) Social Security Number:|37
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|37
15|(M0066) Birth Date:|(M0066) Birth Date:|37
16|(M0069) Gender:|(M0069) Gender:|37
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|37
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|37
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|37
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|37
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|37
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|37
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|37
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|37
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|37
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|37
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|37
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|37
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|37
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|37
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|37
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|37
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|37
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|37
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|37
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|37
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|37
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|37
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|37
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|37
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|37
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|37
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|37
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|37
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|37
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|37
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|37
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|37
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|37
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|37
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|37
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|37
53|(M0300) Current Residence:|(M0300) Current Residence:|37
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|37
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|37
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|37
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|37
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|37
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|37
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|37
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|37
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|37
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|37
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|37
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|37
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|37
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|37
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|37
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|37
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|37
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|37
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|37
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|37
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|37
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|37
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|37
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|37
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|37
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|37
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|37
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|37
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|37
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|37
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|37
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|37
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|37
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|37
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|37
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|37
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|37
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|37
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|37
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|37
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|37
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|37
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|37
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|37
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|37
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|37
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|37
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|37
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|37
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|37
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|37
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|37
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|37
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|37
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|37
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|37
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|37
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|37
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|37
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|37
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|37
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|37
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|37
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|37
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|37
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|37
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|37
144|Wound Care|Wound Care|37
145|Great presidential Moments|Great presidential Moments|37
147|(M0110) Episode Timing|(M0110) Episode Timing|37
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|37
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|37
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|37
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|37
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|37
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|37
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|37
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|37
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|37
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|37
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|37
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|37
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|37
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|37
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|37
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|37
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|37
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|37
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|37
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|37
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|37
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|37
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|37
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|37
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|37
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|37
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|37
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|37
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|37
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|37
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|37
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|37
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|37
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|37
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|37
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|37
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|37
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|37
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|37
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|37
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|37
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|37
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|37
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|37
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|37
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|37
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|37
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|37
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|37
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|37
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|37
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|37
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|37
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|37
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|37
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|37
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|37
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|37
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|37
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|37
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|37
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|37
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|37
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|37
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|37
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|37
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|37
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|37
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|37
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|37
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|37
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|37
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|37
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|37
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|37
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|37
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|37
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|37
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|37
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|37
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|37
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|37
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|37
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|37
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|37
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|37
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|37
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|37
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|37
247|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|37
248|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|37
249|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|37
250|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|37
251|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|37
252|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|37
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|38
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|38
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|38
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|38
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|38
6|(M0040) Patient First Name:|(M0040) Patient First Name:|38
7|(M0040) Patient Last Name|(M0040) Patient Last Name|38
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|38
9|(M0040) Patient Suffix|(M0040) Patient Suffix|38
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|38
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|38
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|38
13|(M0064) Social Security Number:|(M0064) Social Security Number:|38
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|38
15|(M0066) Birth Date:|(M0066) Birth Date:|38
16|(M0069) Gender:|(M0069) Gender:|38
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|38
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|38
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|38
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|38
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|38
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|38
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|38
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|38
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|38
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|38
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|38
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|38
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|38
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|38
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|38
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|38
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|38
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|38
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|38
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|38
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|38
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|38
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|38
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|38
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|38
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|38
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|38
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|38
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|38
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|38
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|38
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|38
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|38
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|38
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|38
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|38
53|(M0300) Current Residence:|(M0300) Current Residence:|38
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|38
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|38
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|38
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|38
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|38
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|38
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|38
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|38
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|38
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|38
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|38
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|38
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|38
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|38
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|38
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|38
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|38
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|38
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|38
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|38
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|38
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|38
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|38
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|38
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|38
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|38
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|38
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|38
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|38
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|38
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|38
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|38
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|38
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|38
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|38
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|38
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|38
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|38
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|38
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|38
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|38
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|38
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|38
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|38
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|38
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|38
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|38
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|38
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|38
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|38
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|38
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|38
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|38
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|38
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|38
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|38
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|38
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|38
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|38
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|38
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|38
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|38
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|38
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|38
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|38
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|38
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|38
144|Wound Care|Wound Care|38
145|Great presidential Moments|Great presidential Moments|38
147|(M0110) Episode Timing|(M0110) Episode Timing|38
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|38
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|38
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|38
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|38
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|38
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|38
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|38
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|38
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|38
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|38
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|38
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|38
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|38
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|38
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|38
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|38
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|38
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|38
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|38
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|38
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|38
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|38
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|38
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|38
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|38
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|38
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|38
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|38
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|38
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|38
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|38
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|38
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|38
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|38
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|38
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|38
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|38
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|38
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|38
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|38
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|38
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|38
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|38
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|38
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|38
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|38
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|38
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|38
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|38
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|38
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|38
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|38
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|38
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|38
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|38
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|38
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|38
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|38
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|38
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|38
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|38
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|38
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|38
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|38
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|38
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|38
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|38
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|38
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|38
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|38
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|38
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|38
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|38
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|38
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|38
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|38
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|38
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|38
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|38
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|38
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|38
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|38
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|38
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|38
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|38
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|38
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|38
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|38
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|38
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|39
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|39
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|39
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|39
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|39
6|(M0040) Patient First Name:|(M0040) Patient First Name:|39
7|(M0040) Patient Last Name|(M0040) Patient Last Name|39
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|39
9|(M0040) Patient Suffix|(M0040) Patient Suffix|39
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|39
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|39
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|39
13|(M0064) Social Security Number:|(M0064) Social Security Number:|39
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|39
15|(M0066) Birth Date:|(M0066) Birth Date:|39
16|(M0069) Gender:|(M0069) Gender:|39
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|39
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|39
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|39
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|39
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|39
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|39
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|39
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|39
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|39
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|39
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|39
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|39
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|39
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|39
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|39
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|39
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|39
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|39
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|39
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|39
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|39
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|39
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|39
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|39
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|39
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|39
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|39
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|39
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|39
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|39
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|39
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|39
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|39
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|39
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|39
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|39
53|(M0300) Current Residence:|(M0300) Current Residence:|39
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|39
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|39
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|39
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|39
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|39
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|39
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|39
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|39
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|39
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|39
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|39
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|39
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|39
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|39
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|39
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|39
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|39
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|39
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|39
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|39
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|39
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|39
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|39
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|39
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|39
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|39
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|39
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|39
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|39
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|39
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|39
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|39
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|39
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|39
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|39
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|39
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|39
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|39
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|39
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|39
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|39
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|39
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|39
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|39
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|39
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|39
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|39
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|39
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|39
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|39
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|39
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|39
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|39
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|39
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|39
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|39
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|39
132|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|39
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|39
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|39
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0903 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|39
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|39
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|39
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|39
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|39
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|39
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|39
144|Wound Care|Wound Care|39
145|Great presidential Moments|Great presidential Moments|39
147|(M0110) Episode Timing|(M0110) Episode Timing|39
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|39
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|39
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|39
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|39
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|39
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|39
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|39
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|39
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|39
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|39
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|39
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|39
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|39
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|39
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|39
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|39
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|39
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|39
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|39
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|39
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|39
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|39
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|39
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|39
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|39
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|39
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|39
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|39
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|39
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|39
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|39
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|39
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|39
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|39
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|39
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|39
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|39
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|39
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|39
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|39
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|39
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|39
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|39
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|39
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|39
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|39
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|39
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|39
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|39
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|39
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|39
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|39
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|39
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|39
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|39
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|39
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|39
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|39
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|39
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|39
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|39
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|39
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|39
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|39
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|39
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|39
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|39
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|39
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|39
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|39
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|39
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|39
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|39
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|39
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|39
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|39
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|39
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|39
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|39
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|39
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|39
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|39
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|39
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|39
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|39
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|39
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|39
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|39
253|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|39
254|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|39
255|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|39
256|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|39
257|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|39
258|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|39
263|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|39
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|41
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|41
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|41
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|41
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|41
6|(M0040) Patient First Name:|(M0040) Patient First Name:|41
7|(M0040) Patient Last Name|(M0040) Patient Last Name|41
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|41
9|(M0040) Patient Suffix|(M0040) Patient Suffix|41
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|41
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|41
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|41
13|(M0064) Social Security Number:|(M0064) Social Security Number:|41
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|41
15|(M0066) Birth Date:|(M0066) Birth Date:|41
16|(M0069) Gender:|(M0069) Gender:|41
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|41
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|41
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|41
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|41
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|41
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|41
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|41
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|41
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|41
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|41
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|41
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|41
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|41
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|41
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|41
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|41
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|41
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|41
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|41
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|41
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|41
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|41
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|41
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|41
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|41
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|41
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|41
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|41
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|41
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|41
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|41
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|41
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|41
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|41
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|41
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|41
53|(M0300) Current Residence:|(M0300) Current Residence:|41
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|41
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|41
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|41
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|41
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|41
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|41
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|41
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|41
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|41
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|41
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|41
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|41
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|41
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|41
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|41
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device:|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|41
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|41
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|41
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|41
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|41
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|41
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|41
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|41
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|41
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|41
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|41
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|41
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|41
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|41
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|41
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|41
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|41
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|41
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|41
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|41
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|41
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|41
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|41
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|41
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|41
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|41
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|41
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|41
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|41
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|41
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|41
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|41
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|41
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|41
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|41
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|41
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|41
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|41
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|41
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|41
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|41
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|41
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|41
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|41
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|41
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|41
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|41
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|41
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|41
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|41
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|41
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|41
144|Wound Care|Wound Care|41
145|Great presidential Moments|Great presidential Moments|41
147|(M0110) Episode Timing|(M0110) Episode Timing|41
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|41
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|41
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|41
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|41
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|41
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|41
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|41
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|41
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|41
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|41
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|41
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|41
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|41
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|41
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|41
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|41
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|41
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|41
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|41
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|41
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|41
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|41
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|41
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|41
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|41
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|41
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|41
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|41
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|41
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|41
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|41
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|41
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|41
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|41
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|41
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|41
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|41
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|41
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|41
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|41
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|41
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|41
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|41
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|41
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|41
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|41
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|41
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|41
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|41
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|41
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|41
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|41
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|41
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|41
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|41
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|41
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|41
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|41
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|41
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|41
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|41
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|41
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|41
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|41
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|41
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|41
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|41
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|41
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|41
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|41
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|41
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|41
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|41
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|41
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|41
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|41
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|41
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|41
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|41
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|41
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|41
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|41
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|41
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|41
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|41
304|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|41
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|41
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|41
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|41
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|41
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|41
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|41
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|43
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|43
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|43
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|43
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|43
6|(M0040) Patient First Name:|(M0040) Patient First Name:|43
7|(M0040) Patient Last Name|(M0040) Patient Last Name|43
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|43
9|(M0040) Patient Suffix|(M0040) Patient Suffix|43
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|43
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|43
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|43
13|(M0064) Social Security Number:|(M0064) Social Security Number:|43
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|43
15|(M0066) Birth Date:|(M0066) Birth Date:|43
16|(M0069) Gender:|(M0069) Gender:|43
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|43
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|43
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|43
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|43
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|43
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|43
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|43
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|43
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|43
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|43
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|43
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|43
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|43
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|43
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|43
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|43
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|43
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|43
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|43
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|43
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|43
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|43
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|43
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|43
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|43
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|43
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|43
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|43
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|43
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|43
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|43
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|43
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|43
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|43
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|43
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|43
53|(M0300) Current Residence:|(M0300) Current Residence:|43
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|43
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|43
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|43
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|43
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|43
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|43
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|43
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|43
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|43
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|43
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|43
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|43
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|43
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|43
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|43
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none):  Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|43
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|43
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|43
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|43
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|43
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|43
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|43
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|43
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|43
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|43
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|43
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|43
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|43
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|43
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|43
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|43
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|43
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|43
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|43
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|43
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|43
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|43
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|43
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|43
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|43
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|43
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|43
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|43
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|43
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|43
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|43
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|43
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|43
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|43
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|43
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|43
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|43
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|43
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|43
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|43
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|43
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|43
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|43
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|43
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|43
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|43
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|43
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|43
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|43
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|43
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|43
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|43
144|Wound Care|Wound Care|43
145|Great presidential Moments|Great presidential Moments|43
147|(M0110) Episode Timing|(M0110) Episode Timing|43
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|43
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|43
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|43
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|43
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|43
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|43
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|43
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|43
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|43
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|43
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|43
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|43
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|43
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|43
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|43
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|43
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|43
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|43
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|43
169|(M1010) d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|43
170|(M1010) e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|43
171|(M1010) f. Inpatient Facility ICD6|(M1010) f. Inpatient Facility ICD6|43
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|43
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|43
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|43
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|43
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|43
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|43
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|43
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|43
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|43
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|43
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|43
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|43
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|43
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|43
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|43
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|43
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|43
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|43
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|43
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|43
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|43
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|43
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|43
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|43
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|43
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|43
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|43
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|43
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|43
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|43
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|43
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|43
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|43
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|43
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|43
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|43
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|43
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|43
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|43
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|43
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|43
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|43
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|43
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|43
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|43
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|43
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|43
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|43
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|43
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|43
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|43
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|43
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|43
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|43
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|43
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|43
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|43
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|43
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|43
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|43
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|43
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|43
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|43
306|(M2102B) ADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|43
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|43
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|43
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|43
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|43
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|43
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|44
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|44
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|44
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|44
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|44
6|(M0040) Patient First Name:|(M0040) Patient First Name:|44
7|(M0040) Patient Last Name|(M0040) Patient Last Name|44
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|44
9|(M0040) Patient Suffix|(M0040) Patient Suffix|44
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|44
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|44
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|44
13|(M0064) Social Security Number:|(M0064) Social Security Number:|44
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|44
15|(M0066) Birth Date:|(M0066) Birth Date:|44
16|(M0069) Gender:|(M0069) Gender:|44
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|44
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|44
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|44
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|44
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|44
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|44
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|44
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|44
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|44
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|44
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|44
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|44
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|44
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|44
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|44
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|44
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|44
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|44
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|44
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|44
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|44
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|44
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|44
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|44
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|44
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|44
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|44
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|44
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|44
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|44
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|44
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|44
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|44
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|44
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|44
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|44
53|(M0300) Current Residence:|(M0300) Current Residence:|44
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|44
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|44
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|44
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|44
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|44
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|44
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|44
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|44
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|44
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|44
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|44
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|44
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|44
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|44
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|44
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|44
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|44
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|44
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|44
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|44
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|44
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|44
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|44
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|44
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|44
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|44
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|44
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|44
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|44
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|44
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|44
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|44
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|44
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|44
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|44
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|44
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|44
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|44
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|44
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|44
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|44
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|44
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|44
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|44
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|44
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|44
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|44
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|44
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|44
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|44
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|44
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|44
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|44
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|44
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|44
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|44
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|44
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|44
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|44
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|44
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|44
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|44
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|44
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|44
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|44
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|44
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|44
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|44
144|Wound Care|Wound Care|44
145|Great presidential Moments|Great presidential Moments|44
147|(M0110) Episode Timing|(M0110) Episode Timing|44
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|44
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|44
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|44
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|44
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|44
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|44
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|44
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|44
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|44
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|44
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|44
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|44
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|44
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|44
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|44
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|44
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|44
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|44
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|44
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|44
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|44
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|44
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|44
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|44
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|44
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|44
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|44
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|44
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|44
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|44
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|44
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|44
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|44
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|44
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|44
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|44
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|44
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|44
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|44
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|44
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|44
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|44
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|44
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|44
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|44
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|44
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|44
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|44
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|44
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|44
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|44
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|44
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|44
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|44
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|44
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|44
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|44
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|44
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|44
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|44
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|44
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|44
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|44
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|44
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|44
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|44
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|44
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|44
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|44
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|44
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|44
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|44
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|44
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|44
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|44
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|44
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|44
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|44
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|44
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|44
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|44
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|44
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|44
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|44
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|44
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|44
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|44
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|45
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|45
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|45
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|45
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|45
6|(M0040) Patient First Name:|(M0040) Patient First Name:|45
7|(M0040) Patient Last Name|(M0040) Patient Last Name|45
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|45
9|(M0040) Patient Suffix|(M0040) Patient Suffix|45
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|45
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|45
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|45
13|(M0064) Social Security Number:|(M0064) Social Security Number:|45
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|45
15|(M0066) Birth Date:|(M0066) Birth Date:|45
16|(M0069) Gender:|(M0069) Gender:|45
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|45
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|45
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|45
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|45
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|45
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|45
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|45
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|45
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|45
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|45
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|45
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|45
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|45
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|45
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|45
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|45
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|45
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|45
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|45
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|45
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|45
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|45
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|45
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|45
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|45
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|45
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|45
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|45
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|45
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|45
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|45
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|45
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|45
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|45
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|45
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|45
53|(M0300) Current Residence:|(M0300) Current Residence:|45
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|45
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|45
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|45
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|45
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|45
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|45
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|45
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|45
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|45
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|45
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|45
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|45
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|45
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|45
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|45
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|45
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|45
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|45
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|45
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|45
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|45
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|45
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|45
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|45
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|45
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|45
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|45
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|45
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|45
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|45
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|45
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|45
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|45
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|45
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|45
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|45
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|45
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|45
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|45
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|45
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|45
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|45
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|45
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|45
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|45
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|45
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|45
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|45
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|45
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|45
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|45
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|45
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|45
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|45
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|45
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|45
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|45
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|45
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|45
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|45
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|45
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|45
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|45
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|45
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|45
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|45
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|45
144|Wound Care|Wound Care|45
145|Great presidential Moments|Great presidential Moments|45
147|(M0110) Episode Timing|(M0110) Episode Timing|45
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|45
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|45
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|45
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|45
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|45
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|45
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|45
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|45
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|45
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|45
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|45
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|45
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|45
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|45
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|45
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|45
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|45
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|45
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|45
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|45
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|45
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|45
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|45
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|45
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|45
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|45
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|45
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|45
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|45
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|45
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|45
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|45
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|45
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|45
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|45
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|45
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|45
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|45
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|45
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|45
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|45
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|45
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|45
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|45
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|45
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|45
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|45
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|45
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|45
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|45
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|45
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|45
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|45
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|45
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|45
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|45
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|45
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|45
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|45
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|45
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|45
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|45
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|45
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|45
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|45
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|45
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|45
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|45
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|45
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|45
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|45
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|45
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|45
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|45
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|45
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|45
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|45
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|45
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|45
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|45
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|45
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|45
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|45
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|45
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|45
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|45
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|45
259|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|45
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|46
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|46
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|46
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|46
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|46
6|(M0040) Patient First Name:|(M0040) Patient First Name:|46
7|(M0040) Patient Last Name|(M0040) Patient Last Name|46
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|46
9|(M0040) Patient Suffix|(M0040) Patient Suffix|46
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|46
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|46
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|46
13|(M0064) Social Security Number:|(M0064) Social Security Number:|46
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|46
15|(M0066) Birth Date:|(M0066) Birth Date:|46
16|(M0069) Gender:|(M0069) Gender:|46
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|46
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|46
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|46
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|46
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|46
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|46
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|46
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|46
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|46
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|46
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|46
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|46
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|46
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|46
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|46
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|46
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|46
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|46
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|46
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|46
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|46
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|46
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|46
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|46
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|46
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|46
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|46
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|46
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|46
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|46
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|46
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|46
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|46
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|46
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|46
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|46
53|(M0300) Current Residence:|(M0300) Current Residence:|46
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|46
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|46
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|46
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|46
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|46
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|46
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|46
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|46
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|46
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|46
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|46
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|46
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|46
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|46
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|46
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|46
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|46
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|46
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|46
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|46
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|46
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|46
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|46
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|46
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|46
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|46
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|46
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|46
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|46
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|46
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|46
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|46
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|46
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|46
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|46
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|46
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|46
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|46
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|46
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|46
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|46
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|46
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|46
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|46
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|46
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|46
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|46
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|46
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|46
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|46
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|46
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|46
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|46
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|46
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|46
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|46
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|46
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|46
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|46
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|46
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|46
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|46
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|46
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|46
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|46
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|46
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|46
144|Wound Care|Wound Care|46
145|Great presidential Moments|Great presidential Moments|46
147|(M0110) Episode Timing|(M0110) Episode Timing|46
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|46
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|46
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|46
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|46
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|46
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|46
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|46
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|46
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|46
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|46
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|46
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|46
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|46
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|46
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|46
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|46
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|46
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|46
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|46
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|46
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|46
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|46
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|46
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|46
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|46
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|46
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|46
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|46
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|46
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|46
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |46
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|46
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|46
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|46
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|46
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|46
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|46
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|46
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|46
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|46
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|46
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|46
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|46
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|46
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|46
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|46
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|46
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|46
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|46
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|46
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|46
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|46
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|46
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|46
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|46
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|46
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|46
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|46
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|46
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|46
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|46
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|46
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|46
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|46
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|46
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|46
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|46
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|46
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|46
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|46
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|46
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|46
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|46
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|46
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|46
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|46
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|46
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|46
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|46
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|46
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|46
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|46
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|46
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|46
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|46
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|46
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|46
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|46
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|46
241|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|46
242|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|46
243|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|46
244|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|46
245|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|46
246|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|46
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|47
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|47
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|47
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|47
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|47
6|(M0040) Patient First Name:|(M0040) Patient First Name:|47
7|(M0040) Patient Last Name|(M0040) Patient Last Name|47
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|47
9|(M0040) Patient Suffix|(M0040) Patient Suffix|47
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|47
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|47
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|47
13|(M0064) Social Security Number:|(M0064) Social Security Number:|47
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|47
15|(M0066) Birth Date:|(M0066) Birth Date:|47
16|(M0069) Gender:|(M0069) Gender:|47
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|47
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|47
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|47
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|47
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|47
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|47
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|47
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|47
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|47
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|47
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|47
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|47
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|47
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|47
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|47
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|47
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|47
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|47
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|47
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|47
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|47
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|47
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|47
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|47
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|47
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|47
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|47
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|47
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|47
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|47
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|47
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|47
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|47
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|47
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|47
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|47
53|(M0300) Current Residence:|(M0300) Current Residence:|47
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|47
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|47
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|47
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|47
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|47
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|47
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|47
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|47
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|47
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|47
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|47
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|47
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|47
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|47
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|47
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|47
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|47
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|47
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|47
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|47
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|47
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|47
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|47
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|47
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|47
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|47
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|47
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|47
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|47
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|47
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|47
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|47
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|47
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|47
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|47
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|47
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|47
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|47
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|47
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|47
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|47
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|47
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|47
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|47
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|47
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|47
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|47
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|47
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|47
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|47
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|47
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|47
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|47
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|47
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|47
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|47
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|47
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|47
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|47
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|47
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|47
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|47
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|47
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|47
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|47
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|47
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|47
144|Wound Care|Wound Care|47
145|Great presidential Moments|Great presidential Moments|47
147|(M0110) Episode Timing|(M0110) Episode Timing|47
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|47
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|47
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|47
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|47
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|47
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|47
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|47
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|47
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|47
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|47
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|47
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|47
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|47
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|47
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|47
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|47
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|47
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|47
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|47
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|47
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|47
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|47
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|47
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|47
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|47
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|47
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|47
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|47
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|47
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|47
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |47
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|47
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|47
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|47
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|47
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|47
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|47
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|47
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|47
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|47
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|47
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|47
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|47
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|47
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|47
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|47
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|47
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|47
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|47
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|47
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|47
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|47
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|47
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|47
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|47
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|47
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|47
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|47
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|47
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|47
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|47
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|47
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|47
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|47
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|47
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|47
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|47
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|47
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|47
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|47
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|47
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|47
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|47
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|47
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|47
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|47
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|47
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|47
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|47
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|47
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|47
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|47
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|47
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|47
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|47
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|47
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|47
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|47
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|47
247|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|47
248|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|47
249|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|47
250|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|47
251|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|47
252|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|47
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|48
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|48
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|48
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|48
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|48
6|(M0040) Patient First Name:|(M0040) Patient First Name:|48
7|(M0040) Patient Last Name|(M0040) Patient Last Name|48
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|48
9|(M0040) Patient Suffix|(M0040) Patient Suffix|48
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|48
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|48
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|48
13|(M0064) Social Security Number:|(M0064) Social Security Number:|48
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|48
15|(M0066) Birth Date:|(M0066) Birth Date:|48
16|(M0069) Gender:|(M0069) Gender:|48
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|48
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|48
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|48
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|48
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|48
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|48
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|48
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|48
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|48
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|48
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|48
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|48
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|48
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|48
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|48
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|48
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|48
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|48
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|48
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|48
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|48
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|48
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|48
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|48
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|48
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|48
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|48
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|48
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|48
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|48
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|48
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|48
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|48
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|48
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|48
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|48
53|(M0300) Current Residence:|(M0300) Current Residence:|48
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|48
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|48
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|48
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|48
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|48
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|48
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|48
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|48
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|48
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|48
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|48
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|48
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|48
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|48
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|48
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|48
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|48
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|48
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|48
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|48
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|48
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|48
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|48
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|48
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|48
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|48
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|48
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|48
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|48
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|48
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|48
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|48
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|48
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|48
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|48
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|48
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|48
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|48
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|48
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|48
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|48
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|48
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|48
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|48
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|48
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|48
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|48
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|48
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|48
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|48
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|48
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|48
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|48
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|48
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|48
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|48
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|48
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|48
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|48
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|48
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|48
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|48
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|48
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|48
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|48
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|48
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|48
144|Wound Care|Wound Care|48
145|Great presidential Moments|Great presidential Moments|48
147|(M0110) Episode Timing|(M0110) Episode Timing|48
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|48
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|48
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|48
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|48
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|48
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|48
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|48
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|48
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|48
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|48
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|48
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|48
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|48
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|48
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|48
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|48
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|48
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|48
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|48
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|48
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|48
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|48
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|48
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|48
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|48
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|48
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|48
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|48
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|48
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|48
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |48
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|48
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|48
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|48
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|48
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|48
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|48
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|48
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|48
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|48
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|48
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|48
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|48
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|48
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|48
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|48
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|48
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|48
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|48
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|48
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|48
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|48
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|48
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|48
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|48
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|48
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|48
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|48
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|48
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|48
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|48
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|48
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|48
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|48
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|48
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|48
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|48
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|48
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|48
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|48
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|48
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|48
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|48
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|48
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|48
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|48
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|48
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|48
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|48
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|48
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|48
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|48
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|48
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|48
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|48
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|48
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|48
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|48
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|48
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|49
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|49
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|49
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|49
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|49
6|(M0040) Patient First Name:|(M0040) Patient First Name:|49
7|(M0040) Patient Last Name|(M0040) Patient Last Name|49
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|49
9|(M0040) Patient Suffix|(M0040) Patient Suffix|49
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|49
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|49
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|49
13|(M0064) Social Security Number:|(M0064) Social Security Number:|49
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|49
15|(M0066) Birth Date:|(M0066) Birth Date:|49
16|(M0069) Gender:|(M0069) Gender:|49
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|49
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|49
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|49
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|49
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|49
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|49
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|49
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|49
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|49
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|49
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|49
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|49
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|49
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|49
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|49
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|49
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|49
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|49
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|49
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|49
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|49
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|49
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|49
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|49
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|49
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|49
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|49
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|49
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|49
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|49
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|49
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|49
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|49
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|49
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|49
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|49
53|(M0300) Current Residence:|(M0300) Current Residence:|49
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|49
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|49
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|49
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|49
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|49
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|49
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|49
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|49
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|49
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|49
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|49
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|49
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|49
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|49
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|49
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|49
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|49
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|49
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|49
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|49
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|49
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|49
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|49
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|49
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|49
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|49
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|49
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|49
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|49
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|49
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|49
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|49
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|49
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|49
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|49
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|49
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|49
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|49
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|49
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|49
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|49
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|49
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|49
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|49
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|49
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|49
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|49
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|49
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|49
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|49
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|49
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|49
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|49
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|49
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|49
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|49
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|49
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|49
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|49
132|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|49
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|49
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|49
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0903 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|49
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|49
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|49
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|49
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|49
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|49
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|49
144|Wound Care|Wound Care|49
145|Great presidential Moments|Great presidential Moments|49
147|(M0110) Episode Timing|(M0110) Episode Timing|49
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|49
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|49
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|49
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|49
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|49
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|49
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|49
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|49
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|49
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|49
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|49
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|49
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|49
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|49
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|49
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|49
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|49
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|49
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|49
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|49
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|49
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|49
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|49
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|49
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|49
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|49
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|49
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|49
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|49
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|49
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |49
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|49
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|49
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|49
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|49
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|49
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|49
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|49
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|49
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|49
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|49
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|49
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|49
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|49
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|49
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|49
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|49
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|49
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|49
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|49
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|49
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|49
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|49
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|49
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|49
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|49
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|49
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|49
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|49
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|49
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|49
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|49
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|49
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|49
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|49
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|49
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|49
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|49
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|49
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|49
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|49
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|49
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|49
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|49
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|49
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|49
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|49
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|49
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|49
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|49
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|49
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|49
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|49
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|49
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|49
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|49
253|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|49
254|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|49
255|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|49
256|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|49
257|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|49
258|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|49
263|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|49
300|(M1309A) Stage II pressure ulcers report the number that are new or have increased in numerical stage since the most recent SOC/ROC (Enter (0» if there are no current Stage II pressure ulcers OR if  all current Stage II existed at most recent SOC/ROC)  |(M1309A) Worsening in Stage II Pressure Ulcer Status since SOC/ROC:|49
301|(M1309B) Stage III pressure ulcers report the number that are new or have increased in numerical stage since the most recent SOC/ROC (Enter (0» if there are no current Stage III pressure ulcers OR if  all current Stage III existed at most recent SOC/ROC)  |(M1309B) Worsening in Stage III Pressure Ulcer Status since SOC/ROC:|49
302|(M1309C) Stage IV pressure ulcers report the number that are new or have increased in numerical stage since the most recent SOC/ROC (Enter (0» if there are no current Stage IV pressure ulcers OR if  all current Stage IV existed at most recent SOC/ROC)  |(M1309C) Worsening in Stage IV Pressure Ulcer Status since SOC/ROC:|49
303|(M1309D) For pressure ulcers that are Unstageable due to slough/eschar report the number that are new or were a Stage I or II at the most recent SOC/ROC. Enter (0» if there are no Unstageable pressure ulcers at discharge OR if all current Unstageable pressure ulcers were Stage III or IV or were Unstageable at most recent SOC/ROC|(M1309D) Worsening in Unstageable Pressure Ulcer Status since SOC/ROC:|49
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|49
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|49
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|49
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|49
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|49
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|49
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|49
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|51
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|51
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|51
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|51
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|51
6|(M0040) Patient First Name:|(M0040) Patient First Name:|51
7|(M0040) Patient Last Name|(M0040) Patient Last Name|51
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|51
9|(M0040) Patient Suffix|(M0040) Patient Suffix|51
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|51
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|51
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|51
13|(M0064) Social Security Number:|(M0064) Social Security Number:|51
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|51
15|(M0066) Birth Date:|(M0066) Birth Date:|51
16|(M0069) Gender:|(M0069) Gender:|51
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|51
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|51
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|51
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|51
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|51
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|51
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|51
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|51
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|51
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|51
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|51
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|51
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|51
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|51
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|51
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|51
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|51
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|51
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|51
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|51
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|51
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|51
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|51
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|51
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|51
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|51
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|51
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|51
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|51
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|51
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|51
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|51
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|51
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|51
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|51
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|51
53|(M0300) Current Residence:|(M0300) Current Residence:|51
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|51
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|51
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|51
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|51
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|51
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|51
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|51
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|51
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|51
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|51
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|51
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|51
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|51
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|51
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|51
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device:|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|51
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|51
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|51
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|51
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|51
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|51
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|51
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|51
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|51
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|51
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|51
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|51
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|51
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|51
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|51
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|51
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|51
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|51
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|51
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|51
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|51
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|51
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|51
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|51
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|51
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|51
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|51
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|51
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|51
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|51
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|51
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|51
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|51
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|51
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|51
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|51
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|51
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|51
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|51
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|51
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|51
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|51
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|51
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|51
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|51
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|51
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|51
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|51
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|51
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|51
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|51
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|51
144|Wound Care|Wound Care|51
145|Great presidential Moments|Great presidential Moments|51
147|(M0110) Episode Timing|(M0110) Episode Timing|51
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|51
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|51
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|51
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|51
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|51
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|51
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|51
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|51
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|51
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|51
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|51
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|51
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|51
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|51
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|51
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|51
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|51
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|51
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|51
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|51
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|51
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|51
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|51
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|51
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|51
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|51
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|51
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|51
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|51
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|51
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|51
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|51
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|51
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|51
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|51
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|51
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|51
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|51
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|51
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|51
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|51
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|51
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|51
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|51
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|51
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|51
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|51
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|51
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|51
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|51
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|51
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|51
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|51
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|51
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|51
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|51
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|51
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|51
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|51
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|51
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|51
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|51
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|51
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|51
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|51
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|51
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|51
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|51
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|51
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|51
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|51
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|51
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|51
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|51
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|51
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|51
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|51
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|51
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|51
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|51
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|51
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|51
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|51
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|51
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|51
304|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|51
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|51
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|51
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|51
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|51
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|51
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|51
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|53
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|53
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|53
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|53
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|53
6|(M0040) Patient First Name:|(M0040) Patient First Name:|53
7|(M0040) Patient Last Name|(M0040) Patient Last Name|53
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|53
9|(M0040) Patient Suffix|(M0040) Patient Suffix|53
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|53
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|53
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|53
13|(M0064) Social Security Number:|(M0064) Social Security Number:|53
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|53
15|(M0066) Birth Date:|(M0066) Birth Date:|53
16|(M0069) Gender:|(M0069) Gender:|53
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|53
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|53
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|53
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|53
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|53
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|53
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|53
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|53
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|53
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|53
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|53
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|53
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|53
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|53
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|53
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|53
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|53
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|53
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|53
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|53
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|53
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|53
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|53
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|53
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|53
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|53
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|53
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|53
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|53
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|53
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|53
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|53
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|53
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|53
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|53
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|53
53|(M0300) Current Residence:|(M0300) Current Residence:|53
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|53
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|53
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|53
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|53
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|53
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|53
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|53
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|53
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|53
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|53
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|53
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|53
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|53
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|53
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|53
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none):  Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|53
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|53
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|53
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|53
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|53
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|53
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|53
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|53
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|53
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|53
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|53
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|53
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|53
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|53
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|53
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|53
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|53
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|53
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|53
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|53
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|53
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|53
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|53
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|53
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|53
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|53
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|53
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|53
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|53
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|53
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|53
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|53
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|53
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|53
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|53
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|53
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|53
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|53
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|53
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|53
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|53
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|53
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|53
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|53
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|53
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|53
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|53
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|53
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|53
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|53
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|53
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|53
144|Wound Care|Wound Care|53
145|Great presidential Moments|Great presidential Moments|53
147|(M0110) Episode Timing|(M0110) Episode Timing|53
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|53
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|53
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|53
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|53
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|53
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|53
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|53
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|53
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|53
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|53
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|53
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|53
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|53
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|53
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|53
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|53
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|53
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|53
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|53
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|53
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|53
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|53
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|53
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|53
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|53
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|53
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|53
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|53
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|53
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|53
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|53
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|53
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|53
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|53
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|53
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|53
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|53
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|53
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|53
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|53
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|53
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|53
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|53
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|53
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|53
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|53
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|53
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|53
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|53
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|53
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|53
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|53
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|53
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|53
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|53
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|53
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|53
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|53
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|53
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|53
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|53
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|53
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|53
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|53
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|53
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|53
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|53
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|53
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|53
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|53
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|53
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|53
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|53
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|53
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|53
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|53
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|53
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|53
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|53
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|53
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|53
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|53
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|53
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|53
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|53
306|(M2102B) ADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|53
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|53
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|53
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|53
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|53
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|53
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|54
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|54
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|54
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|54
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|54
6|(M0040) Patient First Name:|(M0040) Patient First Name:|54
7|(M0040) Patient Last Name|(M0040) Patient Last Name|54
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|54
9|(M0040) Patient Suffix|(M0040) Patient Suffix|54
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|54
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|54
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|54
13|(M0064) Social Security Number:|(M0064) Social Security Number:|54
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|54
15|(M0066) Birth Date:|(M0066) Birth Date:|54
16|(M0069) Gender:|(M0069) Gender:|54
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|54
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|54
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|54
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|54
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|54
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|54
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|54
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|54
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|54
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|54
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|54
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|54
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|54
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|54
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|54
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|54
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|54
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|54
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|54
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|54
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|54
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|54
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|54
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|54
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|54
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|54
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|54
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|54
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|54
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|54
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|54
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|54
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|54
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|54
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|54
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|54
53|(M0300) Current Residence:|(M0300) Current Residence:|54
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|54
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|54
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|54
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|54
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|54
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|54
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|54
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|54
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|54
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|54
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|54
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|54
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|54
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|54
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|54
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|54
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|54
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|54
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|54
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|54
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|54
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|54
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|54
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|54
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|54
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|54
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|54
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|54
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|54
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|54
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|54
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|54
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|54
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|54
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|54
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|54
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|54
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|54
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|54
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|54
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|54
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|54
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|54
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|54
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|54
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|54
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|54
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|54
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|54
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|54
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|54
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|54
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|54
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|54
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|54
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|54
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|54
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|54
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|54
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|54
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|54
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|54
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|54
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|54
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|54
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|54
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|54
144|Wound Care|Wound Care|54
145|Great presidential Moments|Great presidential Moments|54
147|(M0110) Episode Timing|(M0110) Episode Timing|54
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|54
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|54
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|54
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|54
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|54
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|54
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|54
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|54
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|54
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|54
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|54
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|54
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|54
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|54
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|54
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|54
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|54
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|54
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|54
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|54
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|54
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|54
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|54
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|54
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|54
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|54
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|54
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|54
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|54
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|54
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|54
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|54
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|54
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|54
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|54
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|54
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|54
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|54
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|54
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|54
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|54
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|54
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|54
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|54
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|54
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|54
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|54
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|54
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|54
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|54
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|54
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|54
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|54
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|54
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|54
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|54
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|54
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|54
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|54
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|54
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|54
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|54
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|54
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|54
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|54
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|54
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|54
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|54
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|54
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|54
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|54
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|54
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|54
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|54
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|54
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|54
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|54
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|54
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|54
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|54
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|54
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|54
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|54
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|54
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|54
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|54
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|54
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|54
239||(M1005) UK - Inpatient Discharge Date Unknown|54
262|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|54
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|55
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|55
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|55
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|55
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|55
6|(M0040) Patient First Name:|(M0040) Patient First Name:|55
7|(M0040) Patient Last Name|(M0040) Patient Last Name|55
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|55
9|(M0040) Patient Suffix|(M0040) Patient Suffix|55
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|55
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|55
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|55
13|(M0064) Social Security Number:|(M0064) Social Security Number:|55
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|55
15|(M0066) Birth Date:|(M0066) Birth Date:|55
16|(M0069) Gender:|(M0069) Gender:|55
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|55
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|55
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|55
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|55
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|55
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|55
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|55
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|55
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|55
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|55
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|55
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|55
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|55
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|55
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|55
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|55
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|55
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|55
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|55
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|55
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|55
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|55
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|55
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|55
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|55
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|55
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|55
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|55
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|55
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|55
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|55
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|55
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|55
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|55
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|55
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|55
53|(M0300) Current Residence:|(M0300) Current Residence:|55
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|55
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|55
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|55
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|55
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|55
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|55
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|55
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|55
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|55
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|55
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|55
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|55
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|55
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|55
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|55
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|55
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|55
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|55
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|55
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|55
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|55
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|55
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|55
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|55
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|55
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|55
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|55
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|55
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|55
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|55
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|55
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|55
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|55
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|55
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|55
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|55
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|55
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|55
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|55
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|55
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|55
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|55
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|55
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|55
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|55
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|55
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|55
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|55
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|55
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|55
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|55
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|55
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|55
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|55
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|55
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|55
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|55
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|55
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|55
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|55
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|55
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|55
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|55
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|55
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|55
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|55
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|55
144|Wound Care|Wound Care|55
145|Great presidential Moments|Great presidential Moments|55
147|(M0110) Episode Timing|(M0110) Episode Timing|55
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|55
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|55
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|55
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|55
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|55
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|55
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|55
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|55
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|55
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|55
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|55
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|55
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|55
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|55
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|55
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|55
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|55
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|55
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|55
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|55
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|55
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|55
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|55
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|55
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|55
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|55
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|55
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|55
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|55
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|55
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|55
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|55
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|55
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|55
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|55
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|55
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|55
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|55
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|55
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|55
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|55
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|55
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|55
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|55
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|55
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|55
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|55
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|55
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|55
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|55
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|55
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|55
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|55
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|55
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|55
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|55
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|55
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|55
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|55
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|55
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|55
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|55
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|55
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|55
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|55
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|55
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|55
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|55
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|55
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|55
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|55
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|55
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|55
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|55
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|55
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|55
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|55
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|55
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|55
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|55
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|55
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|55
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|55
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|55
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|55
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|55
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|55
259|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|55
260|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|55
261|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|55
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|56
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|56
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|56
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|56
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|56
6|(M0040) Patient First Name:|(M0040) Patient First Name:|56
7|(M0040) Patient Last Name|(M0040) Patient Last Name|56
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|56
9|(M0040) Patient Suffix|(M0040) Patient Suffix|56
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|56
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|56
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|56
13|(M0064) Social Security Number:|(M0064) Social Security Number:|56
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|56
15|(M0066) Birth Date:|(M0066) Birth Date:|56
16|(M0069) Gender:|(M0069) Gender:|56
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|56
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|56
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|56
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|56
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|56
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|56
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|56
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|56
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|56
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|56
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|56
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|56
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|56
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|56
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|56
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|56
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|56
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|56
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|56
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|56
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|56
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|56
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|56
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|56
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|56
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|56
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|56
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|56
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|56
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|56
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|56
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|56
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|56
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|56
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|56
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|56
53|(M0300) Current Residence:|(M0300) Current Residence:|56
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|56
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|56
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|56
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|56
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|56
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|56
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|56
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|56
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|56
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|56
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|56
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|56
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|56
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|56
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|56
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|56
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|56
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|56
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|56
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|56
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|56
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|56
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|56
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|56
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|56
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|56
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|56
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|56
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|56
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|56
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|56
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|56
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|56
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|56
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|56
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|56
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|56
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|56
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|56
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|56
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|56
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|56
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|56
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|56
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|56
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|56
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|56
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|56
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|56
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|56
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|56
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|56
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|56
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|56
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|56
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|56
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|56
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|56
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|56
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|56
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|56
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|56
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|56
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|56
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|56
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|56
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|56
144|Wound Care|Wound Care|56
145|Great presidential Moments|Great presidential Moments|56
147|(M0110) Episode Timing|(M0110) Episode Timing|56
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|56
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|56
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|56
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|56
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|56
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|56
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|56
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|56
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|56
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|56
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|56
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|56
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|56
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|56
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|56
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|56
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|56
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|56
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|56
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|56
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|56
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|56
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|56
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|56
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|56
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|56
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|56
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|56
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|56
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|56
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |56
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|56
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|56
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|56
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|56
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|56
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|56
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|56
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|56
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|56
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|56
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|56
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|56
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|56
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|56
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|56
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|56
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|56
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|56
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|56
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|56
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|56
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|56
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|56
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|56
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|56
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|56
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|56
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|56
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|56
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|56
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|56
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|56
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|56
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|56
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|56
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|56
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|56
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|56
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|56
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|56
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|56
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|56
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|56
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|56
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|56
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|56
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|56
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|56
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|56
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|56
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|56
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|56
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|56
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|56
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|56
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|56
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|56
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|56
241|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|56
242|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|56
243|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|56
244|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|56
245|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|56
246|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|56
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|57
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|57
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|57
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|57
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|57
6|(M0040) Patient First Name:|(M0040) Patient First Name:|57
7|(M0040) Patient Last Name|(M0040) Patient Last Name|57
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|57
9|(M0040) Patient Suffix|(M0040) Patient Suffix|57
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|57
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|57
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|57
13|(M0064) Social Security Number:|(M0064) Social Security Number:|57
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|57
15|(M0066) Birth Date:|(M0066) Birth Date:|57
16|(M0069) Gender:|(M0069) Gender:|57
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|57
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|57
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|57
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|57
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|57
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|57
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|57
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|57
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|57
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|57
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|57
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|57
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|57
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|57
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|57
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|57
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|57
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|57
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|57
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|57
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|57
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|57
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|57
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|57
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|57
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|57
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|57
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|57
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|57
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|57
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|57
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|57
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|57
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|57
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|57
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|57
53|(M0300) Current Residence:|(M0300) Current Residence:|57
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|57
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|57
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|57
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|57
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|57
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|57
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|57
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|57
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|57
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|57
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|57
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|57
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|57
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|57
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|57
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|57
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|57
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|57
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|57
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|57
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|57
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|57
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|57
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|57
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|57
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|57
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|57
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|57
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|57
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|57
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|57
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|57
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|57
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|57
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|57
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|57
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|57
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|57
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|57
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|57
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|57
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|57
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|57
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|57
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|57
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|57
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|57
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|57
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|57
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|57
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|57
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|57
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|57
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|57
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|57
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|57
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|57
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|57
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|57
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|57
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|57
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|57
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|57
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|57
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|57
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|57
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|57
144|Wound Care|Wound Care|57
145|Great presidential Moments|Great presidential Moments|57
147|(M0110) Episode Timing|(M0110) Episode Timing|57
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|57
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|57
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|57
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|57
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|57
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|57
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|57
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|57
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|57
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|57
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|57
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|57
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|57
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|57
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|57
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|57
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|57
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|57
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|57
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|57
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|57
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|57
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|57
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|57
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|57
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|57
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|57
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|57
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|57
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|57
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |57
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|57
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|57
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|57
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|57
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|57
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|57
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|57
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|57
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|57
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|57
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|57
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|57
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|57
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|57
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|57
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|57
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|57
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|57
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|57
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|57
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|57
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|57
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|57
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|57
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|57
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|57
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|57
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|57
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|57
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|57
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|57
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|57
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|57
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|57
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|57
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|57
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|57
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|57
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|57
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|57
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|57
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|57
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|57
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|57
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|57
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|57
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|57
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|57
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|57
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|57
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|57
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|57
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|57
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|57
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|57
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|57
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|57
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|57
247|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|57
248|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|57
249|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|57
250|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|57
251|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|57
252|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|57
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|58
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|58
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|58
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|58
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|58
6|(M0040) Patient First Name:|(M0040) Patient First Name:|58
7|(M0040) Patient Last Name|(M0040) Patient Last Name|58
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|58
9|(M0040) Patient Suffix|(M0040) Patient Suffix|58
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|58
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|58
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|58
13|(M0064) Social Security Number:|(M0064) Social Security Number:|58
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|58
15|(M0066) Birth Date:|(M0066) Birth Date:|58
16|(M0069) Gender:|(M0069) Gender:|58
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|58
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|58
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|58
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|58
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|58
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|58
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|58
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|58
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|58
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|58
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|58
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|58
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|58
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|58
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|58
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|58
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|58
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|58
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|58
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|58
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|58
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|58
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|58
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|58
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|58
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|58
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|58
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|58
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|58
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|58
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|58
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|58
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|58
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|58
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|58
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|58
53|(M0300) Current Residence:|(M0300) Current Residence:|58
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|58
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|58
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|58
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|58
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|58
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|58
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|58
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|58
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|58
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|58
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|58
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|58
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|58
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|58
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|58
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|58
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|58
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|58
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|58
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|58
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|58
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|58
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|58
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|58
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|58
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|58
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|58
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|58
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|58
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|58
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|58
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|58
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|58
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|58
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|58
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|58
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|58
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|58
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|58
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|58
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|58
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|58
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|58
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|58
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|58
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|58
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|58
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|58
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|58
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|58
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|58
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|58
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|58
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|58
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|58
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|58
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|58
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|58
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|58
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|58
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|58
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|58
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|58
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|58
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|58
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|58
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|58
144|Wound Care|Wound Care|58
145|Great presidential Moments|Great presidential Moments|58
147|(M0110) Episode Timing|(M0110) Episode Timing|58
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|58
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|58
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|58
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|58
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|58
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|58
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|58
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|58
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|58
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|58
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|58
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|58
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|58
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|58
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|58
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|58
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|58
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|58
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|58
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|58
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|58
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|58
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|58
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|58
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|58
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|58
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|58
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|58
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|58
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|58
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |58
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|58
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|58
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|58
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|58
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|58
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|58
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|58
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|58
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|58
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|58
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|58
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|58
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|58
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|58
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|58
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|58
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|58
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|58
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|58
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|58
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|58
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|58
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|58
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|58
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|58
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|58
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|58
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|58
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|58
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|58
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|58
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|58
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|58
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|58
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|58
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|58
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|58
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|58
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|58
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|58
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|58
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|58
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|58
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|58
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|58
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|58
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|58
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|58
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|58
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|58
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|58
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|58
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|58
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|58
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|58
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|58
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|58
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|58
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|59
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|59
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|59
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|59
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|59
6|(M0040) Patient First Name:|(M0040) Patient First Name:|59
7|(M0040) Patient Last Name|(M0040) Patient Last Name|59
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|59
9|(M0040) Patient Suffix|(M0040) Patient Suffix|59
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|59
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|59
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|59
13|(M0064) Social Security Number:|(M0064) Social Security Number:|59
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|59
15|(M0066) Birth Date:|(M0066) Birth Date:|59
16|(M0069) Gender:|(M0069) Gender:|59
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|59
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|59
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|59
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|59
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|59
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|59
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|59
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|59
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|59
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|59
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|59
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|59
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|59
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|59
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|59
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|59
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|59
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|59
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|59
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|59
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|59
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|59
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|59
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|59
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|59
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|59
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|59
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|59
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|59
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|59
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|59
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|59
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|59
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|59
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|59
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|59
53|(M0300) Current Residence:|(M0300) Current Residence:|59
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|59
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|59
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|59
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|59
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|59
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|59
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|59
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|59
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|59
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|59
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|59
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|59
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|59
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|59
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|59
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|59
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|59
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|59
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|59
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|59
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|59
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|59
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|59
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|59
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|59
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|59
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|59
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|59
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|59
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|59
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|59
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|59
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|59
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|59
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|59
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|59
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|59
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|59
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|59
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|59
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|59
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|59
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|59
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|59
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|59
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|59
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|59
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|59
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|59
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|59
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|59
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|59
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|59
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|59
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|59
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|59
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|59
132|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|59
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|59
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|59
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0903 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|59
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|59
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|59
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|59
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|59
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|59
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|59
144|Wound Care|Wound Care|59
145|Great presidential Moments|Great presidential Moments|59
147|(M0110) Episode Timing|(M0110) Episode Timing|59
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|59
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|59
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|59
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|59
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|59
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|59
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|59
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|59
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|59
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|59
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|59
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|59
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|59
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|59
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|59
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|59
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|59
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|59
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|59
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|59
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|59
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|59
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|59
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|59
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|59
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|59
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|59
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|59
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|59
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|59
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |59
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|59
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|59
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|59
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|59
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|59
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|59
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|59
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|59
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|59
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|59
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|59
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|59
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|59
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|59
195|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at any point since the previous OASIS assessment?|(M1500) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|59
196|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|59
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|59
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|59
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|59
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|59
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|59
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|59
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|59
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|59
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|59
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|59
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|59
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|59
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|59
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|59
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|59
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|59
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|59
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|59
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|59
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|59
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|59
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|59
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|59
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|59
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|59
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|59
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|59
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|59
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|59
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|59
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|59
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|59
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|59
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|59
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|59
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most recent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|59
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|59
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|59
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|59
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|59
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|59
253|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?  a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care:|(M2400A) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|59
254|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2400B) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|59
255|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment|(M2400C) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|59
256|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2400D) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|59
257|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers|(M2400E) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|59
258|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing|(M2400F) Intervention Synopsis: Since the previous OASIS assessment, were the following intervention|59
263|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|59
300|(M1309A) Stage II pressure ulcers report the number that are new or have increased in numerical stage since the most recent SOC/ROC (Enter (0» if there are no current Stage II pressure ulcers OR if  all current Stage II existed at most recent SOC/ROC)  |(M1309A) Worsening in Stage II Pressure Ulcer Status since SOC/ROC:|59
301|(M1309B) Stage III pressure ulcers report the number that are new or have increased in numerical stage since the most recent SOC/ROC (Enter (0» if there are no current Stage III pressure ulcers OR if  all current Stage III existed at most recent SOC/ROC)  |(M1309B) Worsening in Stage III Pressure Ulcer Status since SOC/ROC:|59
302|(M1309C) Stage IV pressure ulcers report the number that are new or have increased in numerical stage since the most recent SOC/ROC (Enter (0» if there are no current Stage IV pressure ulcers OR if  all current Stage IV existed at most recent SOC/ROC)  |(M1309C) Worsening in Stage IV Pressure Ulcer Status since SOC/ROC:|59
303|(M1309D) For pressure ulcers that are Unstageable due to slough/eschar report the number that are new or were a Stage I or II at the most recent SOC/ROC. Enter (0» if there are no Unstageable pressure ulcers at discharge OR if all current Unstageable pressure ulcers were Stage III or IV or were Unstageable at most recent SOC/ROC|(M1309D) Worsening in Unstageable Pressure Ulcer Status since SOC/ROC:|59
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|59
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|59
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|59
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|59
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|59
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|59
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|59
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|61
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|61
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|61
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|61
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|61
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|61
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|61
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|61
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|61
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|61
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|61
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |61
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|61
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|61
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|61
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |61
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|61
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|61
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|61
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|61
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|61
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|61
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|61
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|61
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|61
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|61
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|61
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|61
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|61
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|61
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|61
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|61
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|61
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|61
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|61
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|61
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|61
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|61
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|61
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|61
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|61
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|61
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|61
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|61
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|61
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|61
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|61
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|61
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|61
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|61
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|61
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|61
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|61
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|61
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|61
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|61
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|61
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|61
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|61
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|61
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|61
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|61
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|61
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|61
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|61
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|61
144|Wound Care|Wound Care|61
145|Great presidential Moments|Great presidential Moments|61
147|(M0110) Episode Timing|(M0110) Episode Timing|61
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|61
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|61
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|61
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|61
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|61
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|61
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|61
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|61
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|61
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|61
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|61
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|61
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|61
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|61
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|61
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|61
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|61
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|61
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|61
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|61
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|61
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|61
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|61
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|61
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|61
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|61
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|61
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|61
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|61
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|61
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|61
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|61
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|61
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|61
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|61
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|61
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|61
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|61
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|61
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|61
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|61
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|61
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|61
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|61
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|61
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|61
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|61
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|61
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|61
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|61
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|61
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|61
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|61
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|61
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|61
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|61
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|61
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|61
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|61
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|61
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|61
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|61
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|61
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|61
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|61
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|61
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|61
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|61
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|61
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|61
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|61
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|61
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|61
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|61
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|61
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|61
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|61
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|61
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|61
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|61
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|61
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|61
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|61
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|61
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|61
304|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|61
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|61
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|61
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|61
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|61
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|61
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|61
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|61
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|61
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|61
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|61
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|61
6|(M0040) Patient First Name:|(M0040) Patient First Name:|61
7|(M0040) Patient Last Name|(M0040) Patient Last Name|61
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|61
9|(M0040) Patient Suffix|(M0040) Patient Suffix|61
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|61
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|61
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|61
13|(M0064) Social Security Number:|(M0064) Social Security Number:|61
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|61
15|(M0066) Birth Date:|(M0066) Birth Date:|61
16|(M0069) Gender:|(M0069) Gender:|61
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|61
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|61
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|61
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|61
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|61
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|61
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|61
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|61
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|61
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|61
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|61
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|61
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|61
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|61
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|61
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|61
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|61
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|61
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|61
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|61
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|61
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|61
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|61
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|61
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|61
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|61
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|61
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|61
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|61
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|61
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|61
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|61
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|61
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|61
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|61
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|61
53|(M0300) Current Residence:|(M0300) Current Residence:|61
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|61
317|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |61
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply|61
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|61
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|61
318|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's discharge goal using the 6-point scale. Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |61
318|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's discharge goal using the 6-point scale. Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |63
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|63
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|63
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply.  |63
317|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |63
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|63
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|63
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|63
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|63
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|63
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|63
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|63
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|63
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|63
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|63
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|63
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|63
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|63
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|63
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|63
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|63
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|63
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|63
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|63
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|63
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|63
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|63
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|63
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|63
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|63
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|63
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|63
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|63
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|63
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|63
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|63
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|63
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|63
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|63
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|63
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|63
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|63
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|63
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|63
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|63
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|63
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|63
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|63
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|63
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited |63
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|63
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|63
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|63
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|63
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|63
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|63
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|63
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|63
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|63
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|63
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|63
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|63
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|63
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|63
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|63
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|63
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|63
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|63
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|63
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|63
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|63
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|63
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|63
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|63
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|63
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|63
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|63
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|63
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|63
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|63
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|63
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|63
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|63
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|63
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|63
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|63
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|63
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|63
306|(M2102B) ADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|63
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|63
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|63
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|63
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|63
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|63
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|63
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|63
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|63
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|63
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|63
6|(M0040) Patient First Name:|(M0040) Patient First Name:|63
7|(M0040) Patient Last Name|(M0040) Patient Last Name|63
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|63
9|(M0040) Patient Suffix|(M0040) Patient Suffix|63
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|63
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|63
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|63
13|(M0064) Social Security Number:|(M0064) Social Security Number:|63
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|63
15|(M0066) Birth Date:|(M0066) Birth Date:|63
16|(M0069) Gender:|(M0069) Gender:|63
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|63
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|63
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|63
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|63
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|63
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|63
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|63
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|63
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|63
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|63
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|63
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|63
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|63
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|63
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|63
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|63
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|63
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|63
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|63
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|63
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|63
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|63
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|63
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|63
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|63
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|63
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|63
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|63
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|63
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|63
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|63
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|63
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|63
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|63
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|63
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|63
53|(M0300) Current Residence:|(M0300) Current Residence:|63
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|63
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|63
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|63
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|63
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|63
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|63
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|63
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|63
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|63
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|63
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|63
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|63
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |63
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|63
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|63
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|63
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|63
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|63
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|63
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|63
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|63
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|63
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|63
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|63
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|63
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|63
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|63
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|63
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|63
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|63
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|63
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|63
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|63
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|63
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|63
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|63
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|63
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|63
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|63
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|63
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|63
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|63
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|63
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|63
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|63
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|63
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|63
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|63
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|63
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|63
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|63
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|63
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|63
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|63
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|63
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|63
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|63
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|63
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|63
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|63
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|63
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|63
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|63
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|63
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|63
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|63
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|63
144|Wound Care|Wound Care|63
145|Great presidential Moments|Great presidential Moments|63
147|(M0110) Episode Timing|(M0110) Episode Timing|63
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|63
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|63
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|64
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|64
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|64
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|64
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|64
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|64
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|64
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|64
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|64
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|64
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|64
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|64
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|64
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|64
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|64
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|64
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|64
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|64
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|64
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|64
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|64
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|64
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|64
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|64
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|64
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|64
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|64
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|64
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|64
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|64
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|64
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|64
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|64
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|64
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|64
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|64
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|64
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|64
53|(M0300) Current Residence:|(M0300) Current Residence:|64
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|64
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|64
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|64
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|64
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|64
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|64
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|64
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|64
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|64
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|64
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|64
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|64
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |64
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|64
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|64
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|64
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |64
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|64
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|64
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|64
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|64
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|64
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|64
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|64
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|64
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|64
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|64
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|64
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|64
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|64
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|64
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|64
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|64
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|64
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|64
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|64
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|64
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|64
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|64
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|64
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|64
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|64
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|64
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|64
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|64
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|64
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|64
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|64
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|64
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|64
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|64
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|64
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|64
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|64
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|64
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|64
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|64
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|64
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|64
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|64
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|64
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|64
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|64
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|64
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|64
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|64
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|64
144|Wound Care|Wound Care|64
145|Great presidential Moments|Great presidential Moments|64
147|(M0110) Episode Timing|(M0110) Episode Timing|64
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|64
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|64
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|64
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|64
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|64
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|64
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|64
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|64
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|64
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|64
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|64
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|64
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|64
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|64
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|64
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|64
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|64
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|64
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|64
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|64
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|64
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|64
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|64
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|64
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|64
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|64
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|64
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|64
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|64
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|64
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|64
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|64
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|64
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|64
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|64
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|64
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|64
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|64
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|64
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|64
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|64
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|64
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|64
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|64
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|64
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|64
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|64
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|64
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|64
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|64
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|64
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|64
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|64
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|64
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|64
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|64
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|64
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|64
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|64
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|64
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|64
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|64
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|64
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|64
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|64
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|64
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|64
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|64
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|64
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|64
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|64
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|64
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|64
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|64
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|64
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|64
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|64
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|64
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |64
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |64
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|64
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |64
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|64
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|64
239||(M1005) UK - Inpatient Discharge Date Unknown|64
262|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|64
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|64
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|64
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|64
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|64
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|64
6|(M0040) Patient First Name:|(M0040) Patient First Name:|64
7|(M0040) Patient Last Name|(M0040) Patient Last Name|64
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|64
9|(M0040) Patient Suffix|(M0040) Patient Suffix|64
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|64
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|64
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|64
13|(M0064) Social Security Number:|(M0064) Social Security Number:|64
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|64
15|(M0066) Birth Date:|(M0066) Birth Date:|64
16|(M0069) Gender:|(M0069) Gender:|64
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|64
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|64
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|65
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|65
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|65
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|65
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|65
6|(M0040) Patient First Name:|(M0040) Patient First Name:|65
7|(M0040) Patient Last Name|(M0040) Patient Last Name|65
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|65
9|(M0040) Patient Suffix|(M0040) Patient Suffix|65
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|65
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|65
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|65
13|(M0064) Social Security Number:|(M0064) Social Security Number:|65
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|65
15|(M0066) Birth Date:|(M0066) Birth Date:|65
16|(M0069) Gender:|(M0069) Gender:|65
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|65
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|65
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|65
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|65
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|65
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|65
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|65
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|65
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|65
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|65
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|65
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|65
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|65
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|65
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|65
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|65
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|65
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|65
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|65
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|65
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|65
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|65
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|65
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|65
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|65
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|65
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|65
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|65
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|65
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|65
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|65
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|65
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|65
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|65
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|65
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|65
53|(M0300) Current Residence:|(M0300) Current Residence:|65
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|65
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|65
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|65
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|65
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|65
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|65
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|65
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|65
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|65
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|65
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|65
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|65
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |65
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|65
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|65
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|65
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |65
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|65
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|65
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|65
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|65
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|65
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|65
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|65
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|65
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|65
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|65
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|65
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|65
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|65
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|65
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|65
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|65
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|65
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|65
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|65
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|65
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|65
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|65
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|65
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|65
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|65
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|65
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|65
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|65
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|65
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|65
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|65
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|65
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|65
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|65
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|65
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|65
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|65
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|65
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|65
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|65
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|65
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|65
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|65
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|65
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|65
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|65
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|65
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|65
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|65
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|65
144|Wound Care|Wound Care|65
145|Great presidential Moments|Great presidential Moments|65
147|(M0110) Episode Timing|(M0110) Episode Timing|65
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|65
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|65
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|65
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|65
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|65
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|65
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|65
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|65
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|65
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|65
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|65
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|65
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|65
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|65
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|65
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|65
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|65
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|65
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|65
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|65
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|65
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|65
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|65
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|65
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|65
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|65
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|65
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|65
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|65
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|65
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|65
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|65
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|65
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|65
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|65
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|65
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|65
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|65
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|65
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|65
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|65
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|65
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|65
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|65
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|65
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|65
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|65
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|65
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|65
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|65
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|65
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|65
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|65
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|65
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|65
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|65
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|65
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|65
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|65
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|65
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|65
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|65
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|65
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|65
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|65
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|65
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|65
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|65
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|65
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|65
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|65
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|65
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|65
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|65
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|65
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|65
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|65
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|65
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|65
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|65
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|65
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|65
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |65
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |65
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|65
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |65
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|65
259|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|65
260|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|65
261|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|65
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|66
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|66
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|66
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|66
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|66
6|(M0040) Patient First Name:|(M0040) Patient First Name:|66
7|(M0040) Patient Last Name|(M0040) Patient Last Name|66
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|66
9|(M0040) Patient Suffix|(M0040) Patient Suffix|66
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|66
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|66
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|66
13|(M0064) Social Security Number:|(M0064) Social Security Number:|66
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|66
15|(M0066) Birth Date:|(M0066) Birth Date:|66
16|(M0069) Gender:|(M0069) Gender:|66
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|66
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|66
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|66
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|66
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|66
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|66
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|66
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|66
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|66
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|66
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|66
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|66
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|66
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|66
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|66
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|66
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|66
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|66
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|66
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|66
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|66
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|66
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|66
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|66
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|66
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|66
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|66
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|66
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|66
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|66
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|66
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|66
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|66
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|66
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|66
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|66
53|(M0300) Current Residence:|(M0300) Current Residence:|66
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|66
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|66
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|66
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|66
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|66
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|66
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|66
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|66
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|66
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|66
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|66
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|66
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|66
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|66
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|66
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|66
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|66
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|66
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|66
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|66
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|66
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|66
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|66
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|66
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|66
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|66
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|66
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|66
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|66
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|66
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|66
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|66
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|66
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|66
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|66
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|66
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|66
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|66
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|66
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|66
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|66
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|66
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|66
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|66
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|66
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|66
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|66
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|66
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|66
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|66
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|66
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|66
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|66
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|66
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|66
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|66
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|66
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|66
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|66
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|66
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|66
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|66
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|66
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|66
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|66
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|66
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|66
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|66
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|66
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|66
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|66
144|Wound Care|Wound Care|66
145|Great presidential Moments|Great presidential Moments|66
147|(M0110) Episode Timing|(M0110) Episode Timing|66
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|66
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|66
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|66
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|66
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|66
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|66
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|66
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|66
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|66
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|66
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|66
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|66
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|66
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|66
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|66
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|66
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|66
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|66
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|66
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|66
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|66
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|66
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|66
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|66
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|66
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|66
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |66
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|66
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|66
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|66
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|66
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|66
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|66
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|66
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|66
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|66
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|66
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|66
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|66
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|66
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|66
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|66
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|66
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|66
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|66
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|66
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|66
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|66
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|66
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|66
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|66
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|66
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|66
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|66
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|66
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|66
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|66
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|66
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|66
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|66
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|66
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|66
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|66
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|66
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|66
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|66
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|66
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|66
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|66
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|66
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|66
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|66
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|66
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|66
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|66
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|66
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|66
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|66
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|66
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|66
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|66
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|66
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|66
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|66
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |66
241|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|66
242|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|66
243|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|66
244|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|66
245|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|66
246|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|66
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|67
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|67
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|67
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|67
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|67
6|(M0040) Patient First Name:|(M0040) Patient First Name:|67
7|(M0040) Patient Last Name|(M0040) Patient Last Name|67
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|67
9|(M0040) Patient Suffix|(M0040) Patient Suffix|67
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|67
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|67
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|67
13|(M0064) Social Security Number:|(M0064) Social Security Number:|67
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|67
15|(M0066) Birth Date:|(M0066) Birth Date:|67
16|(M0069) Gender:|(M0069) Gender:|67
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|67
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|67
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|67
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|67
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|67
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|67
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|67
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|67
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|67
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|67
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|67
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|67
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|67
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|67
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|67
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|67
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|67
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|67
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|67
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|67
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|67
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|67
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|67
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|67
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|67
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|67
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|67
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|67
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|67
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|67
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|67
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|67
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|67
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|67
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|67
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|67
53|(M0300) Current Residence:|(M0300) Current Residence:|67
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|67
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|67
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|67
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|67
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|67
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|67
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|67
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|67
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|67
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|67
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|67
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|67
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|67
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|67
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|67
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|67
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|67
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|67
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|67
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|67
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|67
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|67
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|67
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|67
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|67
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|67
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|67
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|67
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|67
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|67
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|67
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|67
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|67
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|67
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|67
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|67
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|67
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|67
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|67
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|67
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|67
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|67
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|67
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|67
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|67
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|67
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|67
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|67
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|67
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|67
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|67
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|67
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|67
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|67
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|67
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|67
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|67
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|67
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|67
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|67
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|67
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|67
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|67
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|67
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|67
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|67
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|67
144|Wound Care|Wound Care|67
145|Great presidential Moments|Great presidential Moments|67
147|(M0110) Episode Timing|(M0110) Episode Timing|67
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|67
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|67
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|67
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|67
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|67
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|67
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|67
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|67
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|67
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|67
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|67
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|67
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|67
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|67
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|67
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|67
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|67
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|67
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|67
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|67
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|67
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|67
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|67
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|67
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|67
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|67
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|67
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|67
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|67
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|67
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |67
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|67
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|67
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|67
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|67
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|67
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|67
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|67
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|67
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|67
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|67
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|67
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|67
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|67
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|67
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|67
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|67
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|67
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|67
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|67
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|67
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|67
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|67
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|67
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|67
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|67
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|67
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|67
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|67
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|67
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|67
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|67
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|67
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|67
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|67
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|67
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|67
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|67
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|67
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|67
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|67
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|67
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|67
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|67
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|67
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|67
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|67
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|67
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|67
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|67
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|67
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|67
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|67
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|67
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|67
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|67
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|67
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|67
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |67
247|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|67
248|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|67
249|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|67
250|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|67
251|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|67
252|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|67
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|68
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|68
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|68
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|68
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|68
6|(M0040) Patient First Name:|(M0040) Patient First Name:|68
7|(M0040) Patient Last Name|(M0040) Patient Last Name|68
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|68
9|(M0040) Patient Suffix|(M0040) Patient Suffix|68
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|68
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|68
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|68
13|(M0064) Social Security Number:|(M0064) Social Security Number:|68
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|68
15|(M0066) Birth Date:|(M0066) Birth Date:|68
16|(M0069) Gender:|(M0069) Gender:|68
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|68
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|68
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|68
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|68
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|68
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|68
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|68
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|68
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|68
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|68
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|68
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|68
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|68
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|68
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|68
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|68
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|68
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|68
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|68
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|68
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|68
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|68
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|68
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|68
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|68
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|68
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|68
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|68
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|68
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|68
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|68
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|68
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|68
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|68
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|68
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|68
53|(M0300) Current Residence:|(M0300) Current Residence:|68
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|68
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|68
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|68
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|68
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|68
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|68
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|68
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|68
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|68
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|68
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|68
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|68
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|68
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|68
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|68
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|68
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|68
71|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic (Observable) Pressure Ulcer:|68
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|68
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|68
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|68
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|68
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|68
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|68
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|68
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|68
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|68
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|68
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|68
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|68
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|68
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|68
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|68
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|68
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|68
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|68
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|68
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|68
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|68
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|68
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|68
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|68
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|68
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|68
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|68
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|68
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|68
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|68
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|68
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|68
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|68
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|68
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|68
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|68
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|68
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|68
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|68
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|68
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|68
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|68
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|68
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|68
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|68
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|68
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|68
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|68
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|68
144|Wound Care|Wound Care|68
145|Great presidential Moments|Great presidential Moments|68
147|(M0110) Episode Timing|(M0110) Episode Timing|68
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|68
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|68
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|68
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|68
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|68
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|68
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|68
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|68
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|68
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|68
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|68
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|68
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|68
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|68
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|68
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|68
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|68
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|68
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|68
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|68
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|68
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|68
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|68
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|68
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|68
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|68
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|68
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|68
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|68
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|68
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |68
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|68
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|68
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|68
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|68
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|68
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|68
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|68
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|68
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|68
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|68
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|68
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|68
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|68
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|68
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|68
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|68
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|68
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|68
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|68
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|68
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|68
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|68
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|68
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|68
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|68
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|68
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|68
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|68
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|68
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|68
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|68
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|68
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|68
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|68
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|68
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|68
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|68
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|68
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|68
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|68
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|68
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|68
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|68
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|68
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|68
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|68
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|68
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|68
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|68
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|68
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|68
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|68
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|68
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|68
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|68
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|68
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|68
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|68
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|69
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|69
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|69
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|69
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|69
6|(M0040) Patient First Name:|(M0040) Patient First Name:|69
7|(M0040) Patient Last Name|(M0040) Patient Last Name|69
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|69
9|(M0040) Patient Suffix|(M0040) Patient Suffix|69
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|69
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|69
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|69
13|(M0064) Social Security Number:|(M0064) Social Security Number:|69
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|69
15|(M0066) Birth Date:|(M0066) Birth Date:|69
16|(M0069) Gender:|(M0069) Gender:|69
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|69
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|69
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|69
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|69
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|69
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|69
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|69
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|69
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|69
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|69
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|69
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|69
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|69
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|69
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|69
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|69
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|69
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|69
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|69
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|69
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|69
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|69
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|69
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|69
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|69
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|69
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|69
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|69
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|69
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|69
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|69
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|69
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|69
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|69
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|69
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|69
53|(M0300) Current Residence:|(M0300) Current Residence:|69
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|69
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|69
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|69
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|69
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|69
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|69
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|69
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|69
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|69
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|69
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|69
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|69
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |69
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|69
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|69
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressin|69
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |69
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|69
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|69
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|69
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|69
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|69
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|69
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|69
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|69
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|69
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|69
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|69
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|69
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|69
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|69
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|69
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|69
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|69
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|69
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|69
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|69
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|69
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|69
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|69
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|69
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|69
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|69
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|69
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|69
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|69
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|69
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|69
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|69
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|69
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|69
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|69
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|69
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|69
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|69
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|69
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|69
132|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |69
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|69
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|69
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0903 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|69
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|69
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|69
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|69
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|69
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|69
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|69
144|Wound Care|Wound Care|69
145|Great presidential Moments|Great presidential Moments|69
147|(M0110) Episode Timing|(M0110) Episode Timing|69
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|69
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|69
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|69
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|69
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|69
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|69
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|69
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|69
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|69
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|69
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|69
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|69
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|69
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|69
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|69
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|69
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|69
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|69
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|69
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|69
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|69
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|69
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|69
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|69
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|69
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|69
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|69
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|69
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|69
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|69
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |69
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|69
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|69
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|69
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|69
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|69
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|69
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|69
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|69
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|69
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|69
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|69
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|69
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|69
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|69
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|69
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|69
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|69
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|69
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|69
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|69
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|69
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|69
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|69
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|69
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|69
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|69
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|69
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|69
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|69
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|69
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|69
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|69
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|69
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|69
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|69
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|69
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|69
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|69
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|69
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|69
258|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|69
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|69
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|69
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|69
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|69
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|69
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|69
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|69
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|69
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|69
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|69
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|69
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |69
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |69
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|69
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |69
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|69
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|69
253|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|69
254|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|69
255|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|69
256|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|69
257|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|69
263|(M13072D) Date that  Stage 2 Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|69
300|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 2) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 2, enter 0.|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of |69
301|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 3) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 3, enter 0.|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of curr|69
302|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 4) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 4, enter 0.|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of curr|69
303|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to non-removable dressing|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to |69
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|69
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|69
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|69
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|69
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|69
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|69
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|69
315|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were at a Stage 1 or 2 at the most recent SOC/ROC.|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were|69
316|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury in evolution.|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury|69
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|71
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|71
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|71
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|71
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|71
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|71
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|71
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|71
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|71
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|71
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|71
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|71
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|71
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|71
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|71
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|71
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|71
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|71
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|71
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|71
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|71
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|71
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|71
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|71
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|71
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|71
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|71
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|71
144|Wound Care|Wound Care|71
145|Great presidential Moments|Great presidential Moments|71
147|(M0110) Episode Timing|(M0110) Episode Timing|71
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|71
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|71
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|71
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|71
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|71
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|71
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|71
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|71
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|71
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|71
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|71
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|71
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|71
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|71
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|71
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|71
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|71
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|71
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|71
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|71
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|71
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|71
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|71
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|71
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|71
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|71
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|71
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|71
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|71
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|71
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|71
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|71
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|71
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|71
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|71
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|71
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|71
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|71
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|71
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|71
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|71
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|71
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|71
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|71
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|71
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|71
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|71
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|71
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|71
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|71
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|71
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|71
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|71
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|71
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|71
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|71
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|71
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|71
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|71
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|71
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|71
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|71
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|71
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|71
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|71
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|71
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|71
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|71
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|71
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|71
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|71
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|71
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|71
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|71
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|71
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|71
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|71
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|71
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|71
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|71
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|71
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|71
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|71
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|71
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|71
304|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|71
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|71
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|71
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|71
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|71
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|71
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|71
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|71
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|71
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|71
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|71
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|71
6|(M0040) Patient First Name:|(M0040) Patient First Name:|71
7|(M0040) Patient Last Name|(M0040) Patient Last Name|71
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|71
9|(M0040) Patient Suffix|(M0040) Patient Suffix|71
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|71
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|71
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|71
13|(M0064) Social Security Number:|(M0064) Social Security Number:|71
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|71
15|(M0066) Birth Date:|(M0066) Birth Date:|71
16|(M0069) Gender:|(M0069) Gender:|71
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|71
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|71
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|71
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|71
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|71
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|71
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|71
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|71
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|71
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|71
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|71
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|71
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|71
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|71
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|71
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|71
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|71
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|71
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|71
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|71
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|71
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|71
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|71
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|71
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|71
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|71
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|71
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|71
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|71
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|71
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|71
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|71
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|71
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|71
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|71
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|71
53|(M0300) Current Residence:|(M0300) Current Residence:|71
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|71
317|(GG0170C1) Lying to Sitting on Side of Bed (SOC/ROC Perf): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |71
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply|71
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|71
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|71
318|(GG0170C2) Lying to Sitting on Side of Bed (Dschg Goal): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |71
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|71
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|71
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|71
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|71
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|71
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|71
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|71
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|71
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|71
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|71
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|71
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |71
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|71
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|71
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|71
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |71
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|71
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|71
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|71
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|71
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|71
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|71
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|71
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|71
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|71
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|71
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|71
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|71
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|71
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|71
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|71
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|71
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|71
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|71
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|71
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|71
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|71
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|71
329|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes|71
330|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing,|71
319|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Self Care: Code the patient¼s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illnesss, exacerbation, or injury.|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability |71
320|(GG0100B) Prior Functioning (Ambulation): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Indoor Mobility (Ambulation): Code the patient¼s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.|(GG0100B) Prior Functioning (Ambulation): Everyday Activities: Indicate the patient¼s usual ability|71
321|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Stairs: Code the patient¼s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury.|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with|71
322|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Functional Cognition: Code the patient¼s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s |71
323|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,exacerbation, or injury. (Check all that apply)|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illnes|71
324|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid t|71
325|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to|71
326|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (|71
327|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if|71
328|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothe|71
334|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,incl|71
331|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, an|71
332|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;incl|71
333|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;includ|71
335|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,including fasteners; does not include footwear(GG0130G) Lower body dressing: The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,includ|71
336|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks a|71
337|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and|71
338|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and ri|71
339|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and righ|71
340|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying fla|71
341|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat|71
342|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a|71
343|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a c|71
344|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to|71
345|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a|71
346|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode.|71
347|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode.|71
348|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the pa|71
349|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the pass|71
350|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.   (If coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb))|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a roo|71
351|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,|71
357|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or|71
352|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet an|71
353|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and|71
354|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a c|71
355|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a cor|71
356|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven|71
358|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one|71
359|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one s|71
360|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail.|71
361|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail.|71
362|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail.|71
363|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail.|71
364|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to p|71
365|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pic|71
366|(GG0170Q1) Does patient use wheelchair and/or scooter?|(GG0170Q1) Does patient use wheelchair and/or scooter?|71
367|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the abili|71
368|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability|71
369|(GG0170RR1) Indicate the type of wheelchair or scooter used.|(GG0170RR1) Indicate the type of wheelchair or scooter used.|71
370|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at|71
372|(GG0170SS1) Indicate the type of wheelchair or scooter used.|(GG0170SS1) Indicate the type of wheelchair or scooter used.|71
371|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at l|71
371|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at l|73
372|(GG0170SS1) Indicate the type of wheelchair or scooter used.|(GG0170SS1) Indicate the type of wheelchair or scooter used.|73
370|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at|73
369|(GG0170RR1) Indicate the type of wheelchair or scooter used.|(GG0170RR1) Indicate the type of wheelchair or scooter used.|73
368|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability|73
367|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the abili|73
366|(GG0170Q1) Does patient use wheelchair and/or scooter?|(GG0170Q1) Does patient use wheelchair and/or scooter?|73
365|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pic|73
364|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to p|73
363|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail.|73
362|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail.|73
361|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail.|73
360|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail.|73
359|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one s|73
358|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one|73
356|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven|73
355|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a cor|73
354|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a c|73
353|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and|73
352|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet an|73
357|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or|73
351|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,|73
350|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb))|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a roo|73
349|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the pass|73
348|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the pa|73
347|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F2) Toilet tranfer (Dschg Goal): The ability to get on and off a toilet or commode.|73
346|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F1) Toilet tranfer (SOC/ROC Perf): The ability to get on and off a toilet or commode.|73
345|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a|73
344|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to|73
343|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a c|73
342|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a|73
341|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat|73
340|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying fla|73
339|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and righ|73
338|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and ri|73
337|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and|73
336|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks a|73
335|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,including fasteners; does not include footwear Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,includ|73
333|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;includ|73
334|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,incl|73
332|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;incl|73
331|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, an|73
330|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing,|73
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|73
327|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if|73
326|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (|73
328|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothe|73
325|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to|73
324|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid t|73
323|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,exacerbation, or injury. (Check all that apply)|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illnes|73
322|(GG0100D) Prior Functioning (Funtional Cognition): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Functional Cognition: Code the patient¼s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s |73
321|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Stairs: Code the patient¼s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury.|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with|73
320|(GG0100B) Prior Functioning (Indoor Mobility - Ambulation): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Indoor Mobility (Ambulation): Code the patient¼s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.|(GG0100B) Prior Functioning (Indoor Mobility - Ambulation): Everyday Activities: Indicate the |73
319|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Self Care: Code the patient¼s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illnesss, exacerbation, or injury.|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability|73
329|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes|73
318|(GG0170C2) Lying to Sitting on Side of Bed (Dschg Goal): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |73
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|73
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|73
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply.  |73
317|(GG0170C1) Lying to Sitting on Side of Bed (SOC/ROC Perf): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |73
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|73
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|73
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|73
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|73
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|73
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|73
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|73
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|73
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|73
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|73
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|73
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|73
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|73
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|73
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|73
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|73
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|73
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|73
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|73
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|73
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|73
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|73
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|73
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|73
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|73
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|73
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|73
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|73
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|73
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|73
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|73
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|73
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|73
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|73
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|73
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|73
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|73
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|73
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|73
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|73
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|73
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|73
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|73
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|73
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited |73
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|73
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|73
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|73
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|73
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|73
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|73
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|73
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|73
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|73
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|73
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|73
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|73
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|73
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|73
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|73
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|73
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|73
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|73
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|73
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|73
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|73
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|73
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|73
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|73
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|73
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|73
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|73
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|73
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|73
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|73
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|73
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|73
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|73
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|73
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|73
306|(M2102B) ADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|73
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|73
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|73
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|73
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|73
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|73
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|73
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|73
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|73
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|73
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|73
6|(M0040) Patient First Name:|(M0040) Patient First Name:|73
7|(M0040) Patient Last Name|(M0040) Patient Last Name|73
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|73
9|(M0040) Patient Suffix|(M0040) Patient Suffix|73
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|73
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|73
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|73
13|(M0064) Social Security Number:|(M0064) Social Security Number:|73
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|73
15|(M0066) Birth Date:|(M0066) Birth Date:|73
16|(M0069) Gender:|(M0069) Gender:|73
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|73
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|73
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|73
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|73
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|73
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|73
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|73
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|73
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|73
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|73
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|73
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|73
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|73
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|73
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|73
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|73
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|73
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|73
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|73
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|73
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|73
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|73
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|73
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|73
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|73
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|73
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|73
53|(M0300) Current Residence:|(M0300) Current Residence:|73
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|73
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|73
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|73
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|73
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|73
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|73
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|73
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|73
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|73
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|73
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|73
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|73
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |73
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|73
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|73
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|73
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|73
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|73
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|73
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|73
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|73
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|73
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|73
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|73
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|73
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|73
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|73
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|73
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|73
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|73
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|73
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|73
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|73
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|73
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|73
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|73
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|73
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|73
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|73
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|73
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|73
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|73
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|73
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|73
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|73
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|73
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|73
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|73
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|73
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|73
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|73
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|73
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|73
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|73
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|73
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|73
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|73
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|73
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|73
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|73
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|73
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|73
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|73
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|73
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|73
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|73
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|73
144|Wound Care|Wound Care|73
145|Great presidential Moments|Great presidential Moments|73
147|(M0110) Episode Timing|(M0110) Episode Timing|73
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|73
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|73
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|73
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|73
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|73
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|73
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|73
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|73
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|73
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|73
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|73
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|73
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|73
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|74
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|74
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|74
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|74
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|74
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|74
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|74
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|74
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|74
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|74
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|74
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|74
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|74
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|74
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|74
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|74
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|74
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|74
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|74
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|74
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|74
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|74
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|74
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|74
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|74
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|74
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|74
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|74
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|74
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|74
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|74
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|74
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|74
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|74
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|74
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|74
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|74
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|74
53|(M0300) Current Residence:|(M0300) Current Residence:|74
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|74
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|74
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|74
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|74
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|74
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|74
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|74
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|74
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|74
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|74
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|74
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|74
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |74
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|74
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|74
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|74
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |74
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|74
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|74
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|74
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|74
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|74
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|74
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|74
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|74
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|74
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|74
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|74
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|74
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|74
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|74
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|74
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|74
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|74
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|74
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|74
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|74
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|74
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|74
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|74
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|74
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|74
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|74
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|74
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|74
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|74
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|74
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|74
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|74
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|74
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|74
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|74
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|74
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|74
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|74
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|74
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|74
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|74
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|74
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|74
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|74
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|74
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|74
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|74
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|74
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|74
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|74
144|Wound Care|Wound Care|74
145|Great presidential Moments|Great presidential Moments|74
147|(M0110) Episode Timing|(M0110) Episode Timing|74
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|74
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|74
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|74
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|74
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|74
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|74
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|74
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|74
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|74
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|74
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|74
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|74
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|74
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|74
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|74
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|74
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|74
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|74
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|74
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|74
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|74
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|74
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|74
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|74
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|74
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|74
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|74
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|74
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|74
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|74
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|74
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|74
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|74
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|74
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|74
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|74
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|74
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|74
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|74
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|74
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|74
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|74
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|74
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|74
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|74
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|74
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|74
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|74
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|74
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|74
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|74
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|74
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|74
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|74
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|74
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|74
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|74
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|74
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|74
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|74
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|74
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|74
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|74
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|74
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|74
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|74
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|74
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|74
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|74
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|74
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|74
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|74
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|74
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|74
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|74
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|74
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|74
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|74
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |74
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |74
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|74
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |74
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|74
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|74
239||(M1005) UK - Inpatient Discharge Date Unknown|74
262|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|74
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|74
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|74
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|74
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|74
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|74
6|(M0040) Patient First Name:|(M0040) Patient First Name:|74
7|(M0040) Patient Last Name|(M0040) Patient Last Name|74
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|74
9|(M0040) Patient Suffix|(M0040) Patient Suffix|74
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|74
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|74
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|74
13|(M0064) Social Security Number:|(M0064) Social Security Number:|74
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|74
15|(M0066) Birth Date:|(M0066) Birth Date:|74
16|(M0069) Gender:|(M0069) Gender:|74
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|74
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|74
263|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid|74
264|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures|74
265|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clot|74
266|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and|74
277|(GG0170Q4) Does patient use wheelchair and/or scooter?|(GG0170Q4) Does patient use wheelchair and/or scooter?|74
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|74
268|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the b|74
269|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in|74
270|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed t|74
271|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode.|74
272|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a r|74
273|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet|74
274|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneve|74
275|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170Q, Does patient usewheelchair and/or scooter?)|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down o|74
276|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail|74
278|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the abi|74
276|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail|75
274|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneve|75
273|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet|75
272|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a r|75
271|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode.|75
270|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed t|75
269|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in|75
268|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the b|75
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|75
266|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and|75
275|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down one step.  Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.(If coded 07, 09, 10 or 88, skip to GG0170Q, Does patient usewheelchair and/or scooter?)|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down o|75
278|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the abi|75
265|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clot|75
264|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures|75
263|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid|75
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|75
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|75
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|75
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|75
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|75
6|(M0040) Patient First Name:|(M0040) Patient First Name:|75
7|(M0040) Patient Last Name|(M0040) Patient Last Name|75
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|75
9|(M0040) Patient Suffix|(M0040) Patient Suffix|75
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|75
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|75
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|75
13|(M0064) Social Security Number:|(M0064) Social Security Number:|75
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|75
15|(M0066) Birth Date:|(M0066) Birth Date:|75
16|(M0069) Gender:|(M0069) Gender:|75
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|75
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|75
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|75
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|75
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|75
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|75
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|75
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|75
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|75
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|75
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|75
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|75
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|75
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|75
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|75
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|75
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|75
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|75
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|75
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|75
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|75
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|75
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|75
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|75
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|75
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|75
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|75
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|75
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|75
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|75
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|75
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|75
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|75
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|75
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |75
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|75
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|75
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|75
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |75
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|75
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|75
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|75
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|75
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|75
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|75
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|75
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|75
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|75
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|75
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|75
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|75
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|75
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|75
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|75
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|75
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|75
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|75
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|75
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|75
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|75
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|75
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|75
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|75
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|75
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|75
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|75
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|75
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|75
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|75
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|75
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|75
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|75
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|75
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|75
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|75
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|75
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|75
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|75
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|75
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|75
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|75
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|75
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|75
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|75
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|75
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|75
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|75
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|75
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|75
144|Wound Care|Wound Care|75
145|Great presidential Moments|Great presidential Moments|75
147|(M0110) Episode Timing|(M0110) Episode Timing|75
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|75
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|75
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|75
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|75
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|75
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|75
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|75
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|75
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|75
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|75
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|75
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|75
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|75
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|75
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|75
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|75
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|75
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|75
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|75
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|75
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|75
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|75
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|75
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|75
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|75
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|75
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|75
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|75
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|75
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|75
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|75
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|75
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|75
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|75
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|75
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|75
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|75
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|75
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|75
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|75
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|75
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|75
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|75
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|75
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|75
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|75
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|75
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|75
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|75
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|75
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|75
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|75
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|75
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|75
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|75
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|75
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|75
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|75
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|75
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|75
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|75
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|75
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|75
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|75
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|75
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|75
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|75
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|75
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|75
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|75
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|75
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|75
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|75
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|75
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|75
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|75
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|75
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|75
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|75
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|75
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|75
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|75
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |75
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |75
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|75
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |75
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|75
259|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|75
260|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|75
261|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|75
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|75
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|75
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|75
277|(GG0170Q4) Does patient use wheelchair and/or scooter?|(GG0170Q4) Does patient use wheelchair and/or scooter?|75
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|75
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|75
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|75
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|75
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|75
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|75
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|75
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|75
53|(M0300) Current Residence:|(M0300) Current Residence:|75
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|75
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|75
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|75
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|76
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|76
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|76
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|76
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|76
6|(M0040) Patient First Name:|(M0040) Patient First Name:|76
7|(M0040) Patient Last Name|(M0040) Patient Last Name|76
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|76
9|(M0040) Patient Suffix|(M0040) Patient Suffix|76
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|76
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|76
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|76
13|(M0064) Social Security Number:|(M0064) Social Security Number:|76
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|76
15|(M0066) Birth Date:|(M0066) Birth Date:|76
16|(M0069) Gender:|(M0069) Gender:|76
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|76
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|76
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|76
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|76
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|76
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|76
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|76
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|76
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|76
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|76
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|76
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|76
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|76
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|76
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|76
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|76
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|76
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|76
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|76
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|76
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|76
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|76
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|76
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|76
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|76
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|76
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|76
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|76
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|76
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|76
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|76
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|76
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|76
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|76
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|76
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|76
53|(M0300) Current Residence:|(M0300) Current Residence:|76
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|76
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|76
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|76
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|76
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|76
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|76
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|76
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|76
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|76
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|76
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|76
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|76
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|76
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|76
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|76
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|76
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|76
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|76
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|76
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|76
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|76
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|76
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|76
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|76
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|76
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|76
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|76
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|76
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|76
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|76
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|76
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|76
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|76
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|76
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|76
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|76
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|76
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|76
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|76
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|76
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|76
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|76
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|76
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|76
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|76
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|76
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|76
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|76
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|76
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|76
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|76
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|76
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|76
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|76
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|76
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|76
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|76
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|76
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|76
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|76
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|76
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|76
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|76
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|76
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|76
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|76
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|76
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|76
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|76
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|76
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|76
144|Wound Care|Wound Care|76
145|Great presidential Moments|Great presidential Moments|76
147|(M0110) Episode Timing|(M0110) Episode Timing|76
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|76
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|76
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|76
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|76
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|76
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|76
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|76
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|76
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|76
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|76
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|76
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|76
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|76
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|76
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|76
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|76
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|76
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|76
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|76
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|76
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|76
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|76
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|76
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|76
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|76
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|76
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |76
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|76
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|76
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|76
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|76
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|76
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|76
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|76
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|76
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|76
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|76
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|76
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|76
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|76
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|76
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|76
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|76
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|76
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|76
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|76
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|76
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|76
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|76
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|76
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|76
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|76
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|76
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|76
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|76
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|76
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|76
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|76
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|76
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|76
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|76
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|76
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|76
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|76
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|76
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|76
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|76
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|76
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|76
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|76
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|76
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|76
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|76
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|76
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|76
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|76
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|76
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|76
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|76
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|76
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|76
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|76
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|76
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|76
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |76
241|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|76
242|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|76
243|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|76
244|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|76
245|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|76
246|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|76
250|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|76
247|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|76
248|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|76
249|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|76
255|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|77
254|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|77
253|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|77
256|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|77
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|77
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|77
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|77
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|77
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|77
6|(M0040) Patient First Name:|(M0040) Patient First Name:|77
7|(M0040) Patient Last Name|(M0040) Patient Last Name|77
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|77
9|(M0040) Patient Suffix|(M0040) Patient Suffix|77
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|77
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|77
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|77
13|(M0064) Social Security Number:|(M0064) Social Security Number:|77
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|77
15|(M0066) Birth Date:|(M0066) Birth Date:|77
16|(M0069) Gender:|(M0069) Gender:|77
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|77
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|77
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|77
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|77
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|77
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|77
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|77
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|77
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|77
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|77
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|77
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|77
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|77
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|77
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|77
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|77
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|77
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|77
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|77
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|77
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|77
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|77
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|77
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|77
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|77
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|77
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|77
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|77
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|77
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|77
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|77
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|77
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|77
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|77
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|77
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|77
53|(M0300) Current Residence:|(M0300) Current Residence:|77
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|77
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|77
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|77
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|77
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|77
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|77
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|77
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|77
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|77
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|77
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|77
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|77
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|77
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|77
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|77
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|77
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|77
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|77
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|77
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|77
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|77
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|77
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|77
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|77
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|77
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|77
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|77
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|77
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|77
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|77
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|77
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|77
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|77
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|77
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|77
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|77
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|77
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|77
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|77
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|77
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|77
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|77
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|77
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|77
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|77
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|77
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|77
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|77
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|77
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|77
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|77
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|77
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|77
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|77
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|77
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|77
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|77
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|77
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|77
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|77
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|77
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|77
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|77
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|77
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|77
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|77
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|77
144|Wound Care|Wound Care|77
145|Great presidential Moments|Great presidential Moments|77
147|(M0110) Episode Timing|(M0110) Episode Timing|77
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|77
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|77
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|77
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|77
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|77
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|77
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|77
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|77
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|77
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|77
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|77
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|77
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|77
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|77
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|77
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|77
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|77
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|77
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|77
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|77
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|77
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|77
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|77
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|77
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|77
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|77
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|77
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|77
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|77
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|77
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |77
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|77
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|77
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|77
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|77
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|77
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|77
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|77
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|77
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|77
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|77
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|77
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|77
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|77
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|77
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|77
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|77
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|77
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|77
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|77
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|77
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|77
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|77
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|77
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|77
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|77
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|77
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|77
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|77
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|77
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|77
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|77
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|77
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|77
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|77
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|77
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|77
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|77
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|77
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|77
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|77
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|77
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|77
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|77
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|77
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|77
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|77
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|77
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|77
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|77
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|77
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|77
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|77
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|77
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|77
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|77
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|77
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|77
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |77
247|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|77
248|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|77
249|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|77
250|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|77
251|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|77
252|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|77
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|78
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|78
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|78
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|78
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|78
6|(M0040) Patient First Name:|(M0040) Patient First Name:|78
7|(M0040) Patient Last Name|(M0040) Patient Last Name|78
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|78
9|(M0040) Patient Suffix|(M0040) Patient Suffix|78
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|78
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|78
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|78
13|(M0064) Social Security Number:|(M0064) Social Security Number:|78
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|78
15|(M0066) Birth Date:|(M0066) Birth Date:|78
16|(M0069) Gender:|(M0069) Gender:|78
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|78
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|78
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|78
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|78
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|78
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|78
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|78
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|78
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|78
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|78
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|78
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|78
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|78
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|78
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|78
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|78
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|78
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|78
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|78
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|78
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|78
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|78
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|78
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|78
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|78
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|78
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|78
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|78
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|78
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|78
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|78
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|78
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|78
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|78
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|78
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|78
53|(M0300) Current Residence:|(M0300) Current Residence:|78
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|78
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|78
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|78
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|78
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|78
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|78
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|78
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|78
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|78
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|78
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|78
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|78
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|78
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|78
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|78
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|78
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|78
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|78
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|78
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|78
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|78
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|78
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|78
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|78
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|78
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|78
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|78
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|78
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|78
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|78
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|78
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|78
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|78
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|78
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|78
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|78
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|78
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|78
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|78
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|78
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|78
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|78
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|78
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|78
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|78
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|78
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|78
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|78
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|78
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|78
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|78
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|78
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|78
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|78
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|78
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|78
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|78
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|78
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|78
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|78
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|78
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|78
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|78
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|78
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|78
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|78
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|78
144|Wound Care|Wound Care|78
145|Great presidential Moments|Great presidential Moments|78
147|(M0110) Episode Timing|(M0110) Episode Timing|78
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|78
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|78
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|78
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|78
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|78
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|78
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|78
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|78
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|78
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|78
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|78
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|78
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|78
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|78
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|78
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|78
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|78
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|78
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|78
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|78
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|78
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|78
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|78
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|78
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|78
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|78
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|78
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|78
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|78
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|78
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |78
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|78
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|78
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|78
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|78
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|78
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|78
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|78
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|78
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|78
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|78
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|78
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|78
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|78
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|78
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|78
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|78
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|78
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|78
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|78
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|78
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|78
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|78
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|78
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|78
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|78
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|78
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|78
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|78
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|78
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|78
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|78
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|78
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|78
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|78
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|78
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|78
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|78
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|78
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|78
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|78
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|78
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|78
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|78
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|78
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|78
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|78
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|78
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|78
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|78
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|78
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|78
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|78
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|78
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|78
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|78
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|78
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|78
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|78
243|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|78
240|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|78
241|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|78
242|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|78
346|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|79
345|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|79
344|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|79
347|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|79
318|(GG0130B3) Oral Hygiene (Dschg Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B3) Oral Hygiene (Dschg Perf): The ability to use suitable items to clean teeth. Dentures (if|79
319|(GG0130C3) Toileting Hygiene (Dschg Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C3) Toileting Hygiene (Dschg Perf): The ability to maintain perineal hygiene, adjust clothes|79
320|(GG0130E3) Shower/bathe self (Dschg Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E3) Shower/bathe self (Dschg Perf): The ability to bathe self, including washing, rinsing, an|79
321|(GG0130F3) Upper body dressing (Dschg Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F3) Upper body dressing (Dschg Perf): The ability to dress and undress above the waist;includ|79
322|(GG0130G3) Lower body dressing (Dschg Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G3) Lower body dressing (Dschg Perf): The ability to dress and undress below the waist,includ|79
323|(GG0130H3) Putting on/taking off footwear (Dschg Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H3) Putting on/taking off footwear (Dschg Perf): The ability to put on and take off socks and|79
324|(GG0170A3) Roll left and right (Dschg Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A3) Roll left and right (Dschg Perf): The ability to roll from lying on back to left and righ|79
325|(GG0170B3) Sit to lying (Dschg Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B3) Sit to lying (Dschg Perf): The ability to move from sitting on side of bed to lying flat|79
326|(GG0170C3) Lying to sitting on side of bed (Dschg Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C3) Lying to sitting on side of bed (Dschg Perf): The ability to move from lying on the back|79
327|(GG0170D3) Sit to stand (Dschg  Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D3) Sit to stand (Dschg  Perf): The ability to come to a standing position from sitting in a|79
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|79
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|79
328|(GG0170E3) Chair/bed-to-chair transfer (Dschg Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E3) Chair/bed-to-chair transfer (Dschg Perf): The ability to transfer to and from a bed to a|79
329|(GG0170F3) Toilet tranfer (Dschg Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F3) Toilet tranfer (Dschg Perf): The ability to get on and off a toilet or commode.|79
330|(GG0170G3) Car Transfer (Dschg Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G3) Car Transfer (Dschg Perf): The ability to transfer in and out of a car or van on the pass|79
331|(GG0170I3) Walk 10 feet (Dschg Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I3) Walk 10 feet (Dschg Perf): Once standing, the ability to walk at least 10 feet in a room,|79
332|(GG0170J3) Walk 50 feet with two turns (Dschg Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J3) Walk 50 feet with two turns (Dschg Perf): Once standing, the ability to walk 50 feet and|79
333|(GG0170K3) Walk 150 feet (Dschg Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K3) Walk 150 feet (Dschg Perf): Once standing, the ability to walk at least 150 feet in a cor|79
334|(GG0170L3) Walking 10 feet on uneven surfaces (Dschg Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L3) Walking 10 feet on uneven surfaces (Dschg Perf): The ability to walk 10 feet on uneven or|79
335|(GG0170M3) 1 step (curb) (Dschg Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M3) 1 step (curb) (Dschg Perf): The ability to go up and down a curb and/or up and down one s|79
336|(GG0170N3) 4 steps (Dschg Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N3) 4 steps (Dschg Perf): The ability to go up and down four steps with or without a rail. (I|79
337|(GG0170O3) 12 steps (Dschg Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O3) 12 steps (Dschg Perf): The ability to go up and down 12 steps with or without a rail.|79
338|(GG0170P3) Picking up object (Dschg Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P3) Picking up object (Dschg Perf): The ability to bend/stoop from a standing position to pic|79
339|(GG0170Q3) Does patient use wheelchair and/or scooter?|(GG0170Q3) Does patient use wheelchair and/or scooter?|79
340|(GG0170R3) Wheel 50 feet with two turns (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R3) Wheel 50 feet with two turns (Dschg Perf): Once seated in wheelchair/scooter, the ability|79
341|(GG0170RR3) Indicate the type of wheelchair or scooter used.|(GG0170RR3) Indicate the type of wheelchair or scooter used.|79
53|(M0300) Current Residence:|(M0300) Current Residence:|79
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|79
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|79
342|(GG0170S3) Wheel 150 feet (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S3) Wheel 150 feet (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at l|79
343|(GG0170SS3) Indicate the type of wheelchair or scooter used.|(GG0170SS3) Indicate the type of wheelchair or scooter used.|79
317|(GG0130A3) Eating (Dschg Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A3) Eating (Dschg Perf): The ability to use suitable utensils to bring food and/or liquid to|79
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|79
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|79
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|79
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|79
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|79
6|(M0040) Patient First Name:|(M0040) Patient First Name:|79
7|(M0040) Patient Last Name|(M0040) Patient Last Name|79
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|79
9|(M0040) Patient Suffix|(M0040) Patient Suffix|79
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|79
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|79
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|79
13|(M0064) Social Security Number:|(M0064) Social Security Number:|79
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|79
15|(M0066) Birth Date:|(M0066) Birth Date:|79
16|(M0069) Gender:|(M0069) Gender:|79
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|79
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|79
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|79
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|79
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|79
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|79
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|79
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|79
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|79
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|79
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|79
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|79
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|79
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|79
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|79
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|79
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|79
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|79
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|79
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|79
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|79
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|79
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|79
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|79
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|79
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|79
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|79
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|79
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|79
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|79
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|79
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|79
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|79
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|79
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|79
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|79
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|79
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|79
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|79
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|79
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|79
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|79
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|79
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|79
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |79
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|79
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|79
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressin|79
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |79
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|79
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|79
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|79
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|79
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|79
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|79
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|79
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|79
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|79
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|79
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|79
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|79
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|79
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|79
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|79
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|79
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|79
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|79
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|79
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|79
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|79
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|79
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|79
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|79
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|79
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|79
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|79
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|79
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|79
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|79
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|79
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|79
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|79
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|79
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|79
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|79
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|79
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|79
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|79
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|79
132|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |79
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|79
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|79
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0906 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|79
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|79
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|79
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|79
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|79
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|79
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|79
144|Wound Care|Wound Care|79
145|Great presidential Moments|Great presidential Moments|79
147|(M0110) Episode Timing|(M0110) Episode Timing|79
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|79
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|79
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|79
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|79
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|79
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|79
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|79
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|79
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|79
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|79
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|79
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|79
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|79
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|79
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|79
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|79
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|79
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|79
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|79
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|79
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|79
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|79
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|79
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|79
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|79
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|79
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|79
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|79
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|79
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|79
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |79
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|79
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|79
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|79
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|79
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|79
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|79
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|79
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|79
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|79
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|79
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|79
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|79
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|79
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|79
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|79
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|79
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|79
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|79
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|79
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|79
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|79
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|79
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|79
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|79
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|79
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|79
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|79
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|79
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|79
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|79
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|79
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|79
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|79
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|79
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|79
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|79
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|79
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|79
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|79
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|79
258|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|79
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|79
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|79
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|79
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|79
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|79
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|79
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|79
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|79
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|79
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|79
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|79
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |79
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |79
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|79
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |79
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|79
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|79
253|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|79
254|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|79
255|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|79
256|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|79
257|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|79
263|(M13072D) Date that  Stage 2 Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|79
300|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 2) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 2, enter 0.|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of |79
301|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 3) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 3, enter 0.|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of curr|79
302|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 4) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 4, enter 0.|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of curr|79
303|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to non-removable dressing|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to |79
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|79
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|79
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|79
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|79
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|79
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|79
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|79
315|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were at a Stage 1 or 2 at the most recent SOC/ROC.|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were|79
316|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury in evolution.|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury|79
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|81
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|81
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|81
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|81
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|81
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|81
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|81
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|81
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|81
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|81
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|81
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|81
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|81
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|81
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|81
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|81
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|81
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|81
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|81
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|81
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|81
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|81
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|81
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|81
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|81
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|81
304|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|81
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|81
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|81
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|81
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|81
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|81
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|81
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|81
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|81
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|81
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|81
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|81
6|(M0040) Patient First Name:|(M0040) Patient First Name:|81
7|(M0040) Patient Last Name|(M0040) Patient Last Name|81
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|81
9|(M0040) Patient Suffix|(M0040) Patient Suffix|81
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|81
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|81
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|81
13|(M0064) Social Security Number:|(M0064) Social Security Number:|81
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|81
15|(M0066) Birth Date:|(M0066) Birth Date:|81
16|(M0069) Gender:|(M0069) Gender:|81
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|81
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|81
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|81
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|81
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|81
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|81
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|81
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|81
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|81
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|81
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|81
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|81
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|81
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|81
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|81
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|81
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|81
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|81
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|81
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|81
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|81
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|81
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|81
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|81
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|81
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|81
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|81
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|81
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|81
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|81
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|81
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|81
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|81
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|81
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|81
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|81
53|(M0300) Current Residence:|(M0300) Current Residence:|81
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|81
317|(GG0170C1) Lying to Sitting on Side of Bed (SOC/ROC Perf): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |81
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply|81
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|81
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|81
318|(GG0170C2) Lying to Sitting on Side of Bed (Dschg Goal): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |81
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|81
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|81
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|81
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|81
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|81
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|81
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|81
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|81
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|81
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|81
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|81
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |81
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|81
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|81
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|81
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |81
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|81
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|81
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|81
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|81
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|81
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|81
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|81
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|81
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|81
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|81
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|81
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|81
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|81
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|81
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|81
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|81
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|81
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|81
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|81
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|81
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|81
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|81
329|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes|81
330|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing,|81
319|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Self Care: Code the patient¼s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illnesss, exacerbation, or injury.|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability |81
320|(GG0100B) Prior Functioning (Ambulation): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Indoor Mobility (Ambulation): Code the patient¼s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.|(GG0100B) Prior Functioning (Ambulation): Everyday Activities: Indicate the patient¼s usual ability|81
321|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Stairs: Code the patient¼s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury.|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with|81
322|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Functional Cognition: Code the patient¼s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s |81
323|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,exacerbation, or injury. (Check all that apply)|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illnes|81
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|81
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|81
324|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid t|81
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|81
325|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to|81
326|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (|81
327|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if|81
328|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothe|81
334|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,incl|81
331|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, an|81
332|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;incl|81
333|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;includ|81
335|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,including fasteners; does not include footwear(GG0130G) Lower body dressing: The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,includ|81
336|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks a|81
337|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and|81
338|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and ri|81
339|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and righ|81
340|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying fla|81
341|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat|81
342|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a|81
343|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a c|81
344|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to|81
345|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a|81
346|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode.|81
347|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode.|81
348|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the pa|81
349|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the pass|81
350|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.   (If coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb))|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a roo|81
351|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,|81
357|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or|81
352|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet an|81
353|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and|81
354|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a c|81
355|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a cor|81
356|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven|81
358|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one|81
359|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one s|81
360|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail.|81
361|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail.|81
362|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail.|81
363|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail.|81
364|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to p|81
365|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pic|81
366|(GG0170Q1) Does patient use wheelchair and/or scooter?|(GG0170Q1) Does patient use wheelchair and/or scooter?|81
367|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the abili|81
368|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability|81
369|(GG0170RR1) Indicate the type of wheelchair or scooter used.|(GG0170RR1) Indicate the type of wheelchair or scooter used.|81
370|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at|81
372|(GG0170SS1) Indicate the type of wheelchair or scooter used.|(GG0170SS1) Indicate the type of wheelchair or scooter used.|81
371|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at l|81
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|81
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|81
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|81
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|81
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|81
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|81
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|81
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|81
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|81
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|81
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|81
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|81
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|81
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|81
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|81
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|81
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|81
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|81
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|81
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|81
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|81
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|81
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|81
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|81
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|81
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|81
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|81
144|Wound Care|Wound Care|81
145|Great presidential Moments|Great presidential Moments|81
147|(M0110) Episode Timing|(M0110) Episode Timing|81
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|81
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|81
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|81
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|81
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|81
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|81
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|81
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|81
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|81
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|81
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|81
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|81
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|81
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|81
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|81
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|81
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|81
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|81
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|81
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|81
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|81
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|81
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|81
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|81
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|81
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|81
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|81
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|81
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|81
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|81
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|81
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|81
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|81
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|81
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|81
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|81
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|81
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|81
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|81
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|81
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|81
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|81
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|81
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|81
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|81
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|81
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|81
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|81
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|81
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|81
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|81
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|81
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|81
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|81
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|81
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|81
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|81
365|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pic|83
364|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to p|83
363|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail.|83
362|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail.|83
361|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail.|83
360|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail.|83
359|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one s|83
358|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one|83
356|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven|83
355|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a cor|83
354|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a c|83
353|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and|83
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|83
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|83
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|83
352|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet an|83
357|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or|83
351|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,|83
350|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb))|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a roo|83
349|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the pass|83
348|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the pa|83
347|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F2) Toilet tranfer (Dschg Goal): The ability to get on and off a toilet or commode.|83
346|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F1) Toilet tranfer (SOC/ROC Perf): The ability to get on and off a toilet or commode.|83
345|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a|83
344|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to|83
343|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a c|83
342|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a|83
341|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat|83
340|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying fla|83
339|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and righ|83
338|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and ri|83
337|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and|83
336|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks a|83
335|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,including fasteners; does not include footwear Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,includ|83
333|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;includ|83
334|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,incl|83
332|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;incl|83
331|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, an|83
330|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing,|83
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|83
327|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if|83
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|83
326|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (|83
328|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothe|83
325|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to|83
324|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid t|83
323|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,exacerbation, or injury. (Check all that apply)|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illnes|83
322|(GG0100D) Prior Functioning (Funtional Cognition): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Functional Cognition: Code the patient¼s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s |83
321|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Stairs: Code the patient¼s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury.|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with|83
320|(GG0100B) Prior Functioning (Indoor Mobility - Ambulation): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Indoor Mobility (Ambulation): Code the patient¼s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.|(GG0100B) Prior Functioning (Indoor Mobility - Ambulation): Everyday Activities: Indicate the |83
319|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Self Care: Code the patient¼s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illnesss, exacerbation, or injury.|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability|83
329|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes|83
318|(GG0170C2) Lying to Sitting on Side of Bed (Dschg Goal): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |83
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|83
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|83
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply.  |83
317|(GG0170C1) Lying to Sitting on Side of Bed (SOC/ROC Perf): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |83
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|83
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|83
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|83
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|83
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|83
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|83
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|83
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|83
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|83
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|83
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|83
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|83
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|83
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|83
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|83
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|83
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|83
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|83
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|83
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|83
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|83
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|83
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|83
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|83
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|83
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|83
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|83
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|83
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|83
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|83
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|83
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|83
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|83
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|83
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|83
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|83
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited |83
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|83
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|83
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|83
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|83
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|83
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|83
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|83
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|83
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|83
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|83
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|83
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|83
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|83
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|83
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|83
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|83
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|83
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|83
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|83
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|83
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|83
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|83
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|83
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|83
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|83
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|83
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|83
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|83
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|83
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|83
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|83
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|83
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|83
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|83
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|83
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|83
306|(M2102B) ADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|83
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|83
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|83
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|83
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|83
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|83
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|83
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|83
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|83
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|83
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|83
6|(M0040) Patient First Name:|(M0040) Patient First Name:|83
7|(M0040) Patient Last Name|(M0040) Patient Last Name|83
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|83
9|(M0040) Patient Suffix|(M0040) Patient Suffix|83
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|83
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|83
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|83
13|(M0064) Social Security Number:|(M0064) Social Security Number:|83
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|83
15|(M0066) Birth Date:|(M0066) Birth Date:|83
16|(M0069) Gender:|(M0069) Gender:|83
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|83
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|83
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|83
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|83
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|83
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|83
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|83
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|83
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|83
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|83
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|83
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|83
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|83
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|83
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|83
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|83
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|83
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|83
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|83
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|83
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|83
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|83
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|83
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|83
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|83
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|83
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|83
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|83
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|83
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|83
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|83
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|83
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|83
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|83
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|83
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|83
53|(M0300) Current Residence:|(M0300) Current Residence:|83
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|83
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|83
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|83
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|83
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|83
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|83
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|83
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|83
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|83
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|83
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|83
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|83
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |83
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|83
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|83
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|83
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|83
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|83
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|83
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|83
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|83
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|83
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|83
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|83
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|83
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|83
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|83
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|83
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|83
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|83
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|83
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|83
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|83
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|83
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|83
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|83
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|83
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|83
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|83
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|83
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|83
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|83
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|83
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|83
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|83
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|83
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|83
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|83
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|83
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|83
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|83
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|83
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|83
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|83
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|83
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|83
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|83
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|83
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|83
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|83
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|83
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|83
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|83
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|83
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|83
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|83
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|83
144|Wound Care|Wound Care|83
145|Great presidential Moments|Great presidential Moments|83
147|(M0110) Episode Timing|(M0110) Episode Timing|83
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|83
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|83
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|83
371|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at l|83
372|(GG0170SS1) Indicate the type of wheelchair or scooter used.|(GG0170SS1) Indicate the type of wheelchair or scooter used.|83
370|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at|83
369|(GG0170RR1) Indicate the type of wheelchair or scooter used.|(GG0170RR1) Indicate the type of wheelchair or scooter used.|83
368|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability|83
367|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the abili|83
366|(GG0170Q1) Does patient use wheelchair and/or scooter?|(GG0170Q1) Does patient use wheelchair and/or scooter?|83
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|83
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|83
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|83
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|83
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|84
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|84
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|84
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|84
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|84
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|84
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|84
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|84
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|84
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|84
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|84
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|84
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|84
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|84
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|84
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|84
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|84
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|84
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|84
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|84
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|84
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|84
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|84
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|84
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|84
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|84
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|84
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|84
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|84
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|84
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|84
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|84
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|84
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|84
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|84
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|84
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|84
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|84
53|(M0300) Current Residence:|(M0300) Current Residence:|84
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|84
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|84
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|84
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|84
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|84
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|84
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|84
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|84
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|84
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|84
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|84
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|84
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |84
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|84
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|84
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|84
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |84
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|84
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|84
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|84
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|84
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|84
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|84
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|84
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|84
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|84
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|84
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|84
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|84
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|84
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|84
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|84
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|84
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|84
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|84
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|84
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|84
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|84
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|84
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|84
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|84
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|84
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|84
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|84
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|84
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|84
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|84
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|84
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|84
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|84
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|84
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|84
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|84
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|84
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|84
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|84
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|84
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|84
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|84
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|84
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|84
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|84
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|84
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|84
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|84
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|84
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|84
144|Wound Care|Wound Care|84
145|Great presidential Moments|Great presidential Moments|84
147|(M0110) Episode Timing|(M0110) Episode Timing|84
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|84
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|84
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|84
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|84
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|84
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|84
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|84
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|84
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|84
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|84
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|84
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|84
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|84
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|84
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|84
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|84
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|84
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|84
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|84
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|84
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|84
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|84
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|84
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|84
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|84
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|84
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|84
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|84
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|84
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|84
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|84
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|84
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|84
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|84
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|84
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|84
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|84
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|84
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|84
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|84
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|84
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|84
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|84
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|84
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|84
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|84
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|84
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|84
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|84
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|84
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|84
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|84
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|84
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|84
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|84
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|84
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|84
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|84
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|84
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|84
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|84
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|84
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|84
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|84
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|84
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|84
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|84
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|84
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|84
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|84
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|84
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|84
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|84
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|84
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|84
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|84
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|84
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|84
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |84
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |84
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|84
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |84
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|84
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|84
239||(M1005) UK - Inpatient Discharge Date Unknown|84
262|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|84
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|84
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|84
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|84
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|84
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|84
6|(M0040) Patient First Name:|(M0040) Patient First Name:|84
7|(M0040) Patient Last Name|(M0040) Patient Last Name|84
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|84
9|(M0040) Patient Suffix|(M0040) Patient Suffix|84
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|84
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|84
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|84
13|(M0064) Social Security Number:|(M0064) Social Security Number:|84
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|84
15|(M0066) Birth Date:|(M0066) Birth Date:|84
16|(M0069) Gender:|(M0069) Gender:|84
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|84
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|84
263|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid|84
264|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures|84
265|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clot|84
266|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and|84
277|(GG0170Q4) Does patient use wheelchair and/or scooter?|(GG0170Q4) Does patient use wheelchair and/or scooter?|84
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|84
268|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the b|84
269|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in|84
270|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed t|84
271|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode.|84
272|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a r|84
273|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet|84
274|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneve|84
275|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170Q, Does patient usewheelchair and/or scooter?)|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down o|84
276|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail|84
278|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the abi|84
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|85
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|85
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|85
276|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail|85
274|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneve|85
273|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet|85
272|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a r|85
271|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode.|85
270|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed t|85
269|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in|85
268|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the b|85
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|85
266|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and|85
275|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down one step.  Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.(If coded 07, 09, 10 or 88, skip to GG0170Q, Does patient usewheelchair and/or scooter?)|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down o|85
277|(GG0170Q4) Does patient use wheelchair and/or scooter?|(GG0170Q4) Does patient use wheelchair and/or scooter?|85
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|85
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|85
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|85
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|85
278|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the abi|85
265|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clot|85
264|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures|85
263|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid|85
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|85
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|85
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|85
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|85
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|85
6|(M0040) Patient First Name:|(M0040) Patient First Name:|85
7|(M0040) Patient Last Name|(M0040) Patient Last Name|85
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|85
9|(M0040) Patient Suffix|(M0040) Patient Suffix|85
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|85
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|85
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|85
13|(M0064) Social Security Number:|(M0064) Social Security Number:|85
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|85
15|(M0066) Birth Date:|(M0066) Birth Date:|85
16|(M0069) Gender:|(M0069) Gender:|85
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|85
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|85
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|85
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|85
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|85
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|85
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|85
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|85
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|85
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|85
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|85
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|85
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|85
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|85
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|85
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|85
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|85
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|85
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|85
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|85
53|(M0300) Current Residence:|(M0300) Current Residence:|85
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|85
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|85
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|85
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|85
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|85
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|85
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|85
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|85
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|85
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|85
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|85
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|85
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |85
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|85
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|85
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|85
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |85
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|85
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|85
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|85
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|85
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|85
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|85
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|85
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|85
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|85
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|85
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|85
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|85
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|85
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|85
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|85
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|85
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|85
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|85
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|85
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|85
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|85
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|85
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|85
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|85
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|85
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|85
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|85
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|85
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|85
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|85
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|85
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|85
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|85
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|85
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|85
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|85
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|85
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|85
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|85
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|85
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|85
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|85
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|85
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|85
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|85
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|85
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|85
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|85
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|85
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|85
144|Wound Care|Wound Care|85
145|Great presidential Moments|Great presidential Moments|85
147|(M0110) Episode Timing|(M0110) Episode Timing|85
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|85
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|85
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|85
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|85
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|85
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|85
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|85
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|85
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|85
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|85
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|85
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|85
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|85
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|85
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|85
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|85
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|85
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|85
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|85
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|85
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|85
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|85
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|85
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|85
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|85
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|85
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|85
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|85
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|85
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|85
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|85
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|85
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|85
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|85
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|85
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|85
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|85
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|85
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|85
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|85
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|85
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|85
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|85
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|85
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|85
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|85
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|85
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|85
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|85
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|85
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|85
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|85
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|85
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|85
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|85
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|85
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|85
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|85
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|85
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|85
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|85
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|85
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|85
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|85
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|85
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|85
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|85
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|85
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|85
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|85
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|85
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|85
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|85
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|85
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|85
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|85
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|85
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|85
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|85
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|85
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|85
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|85
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |85
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |85
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|85
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |85
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|85
259|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|85
260|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|85
261|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|85
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|85
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|85
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|85
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|85
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|85
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|85
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|85
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|85
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|85
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|86
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|86
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|86
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|86
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|86
6|(M0040) Patient First Name:|(M0040) Patient First Name:|86
7|(M0040) Patient Last Name|(M0040) Patient Last Name|86
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|86
9|(M0040) Patient Suffix|(M0040) Patient Suffix|86
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|86
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|86
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|86
13|(M0064) Social Security Number:|(M0064) Social Security Number:|86
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|86
15|(M0066) Birth Date:|(M0066) Birth Date:|86
16|(M0069) Gender:|(M0069) Gender:|86
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|86
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|86
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|86
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|86
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|86
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|86
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|86
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|86
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|86
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|86
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|86
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|86
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|86
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|86
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|86
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|86
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|86
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|86
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|86
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|86
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|86
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|86
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|86
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|86
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|86
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|86
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|86
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|86
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|86
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|86
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|86
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|86
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|86
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|86
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|86
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|86
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|86
53|(M0300) Current Residence:|(M0300) Current Residence:|86
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|86
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|86
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|86
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|86
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|86
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|86
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|86
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|86
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|86
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|86
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|86
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|86
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|86
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|86
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|86
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|86
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|86
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|86
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|86
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|86
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|86
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|86
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|86
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|86
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|86
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|86
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|86
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|86
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|86
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|86
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|86
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|86
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|86
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|86
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|86
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|86
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|86
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|86
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|86
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|86
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|86
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|86
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|86
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|86
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|86
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|86
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|86
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|86
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|86
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|86
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|86
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|86
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|86
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|86
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|86
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|86
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|86
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|86
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|86
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|86
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|86
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|86
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|86
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|86
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|86
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|86
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|86
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|86
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|86
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|86
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|86
144|Wound Care|Wound Care|86
145|Great presidential Moments|Great presidential Moments|86
147|(M0110) Episode Timing|(M0110) Episode Timing|86
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|86
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|86
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|86
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|86
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|86
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|86
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|86
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|86
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|86
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|86
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|86
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|86
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|86
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|86
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|86
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|86
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|86
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|86
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|86
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|86
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|86
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|86
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|86
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|86
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|86
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |86
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|86
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|86
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|86
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|86
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|86
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|86
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|86
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|86
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|86
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|86
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|86
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|86
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|86
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|86
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|86
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|86
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|86
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|86
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|86
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|86
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|86
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|86
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|86
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|86
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|86
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|86
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|86
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|86
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|86
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|86
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|86
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|86
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|86
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|86
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|86
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|86
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|86
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|86
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|86
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|86
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|86
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|86
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|86
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|86
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|86
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|86
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|86
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|86
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|86
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|86
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|86
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|86
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|86
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|86
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|86
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|86
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|86
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |86
241|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|86
242|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|86
243|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|86
244|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|86
245|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|86
246|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|86
250|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|86
247|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|86
248|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|86
249|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|86
255|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|87
254|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|87
253|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|87
256|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|87
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|87
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|87
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|87
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|87
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|87
6|(M0040) Patient First Name:|(M0040) Patient First Name:|87
7|(M0040) Patient Last Name|(M0040) Patient Last Name|87
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|87
9|(M0040) Patient Suffix|(M0040) Patient Suffix|87
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|87
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|87
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|87
13|(M0064) Social Security Number:|(M0064) Social Security Number:|87
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|87
15|(M0066) Birth Date:|(M0066) Birth Date:|87
16|(M0069) Gender:|(M0069) Gender:|87
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|87
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|87
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|87
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|87
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|87
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|87
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|87
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|87
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|87
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|87
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|87
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|87
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|87
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|87
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|87
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|87
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|87
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|87
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|87
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|87
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|87
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|87
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|87
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|87
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|87
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|87
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|87
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|87
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|87
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|87
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|87
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|87
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|87
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|87
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|87
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|87
53|(M0300) Current Residence:|(M0300) Current Residence:|87
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|87
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|87
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|87
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|87
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|87
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|87
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|87
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|87
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|87
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|87
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|87
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|87
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|87
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|87
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|87
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|87
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|87
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|87
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|87
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|87
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|87
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|87
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|87
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|87
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|87
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|87
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|87
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|87
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|87
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|87
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|87
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|87
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|87
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|87
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|87
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|87
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|87
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|87
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|87
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|87
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|87
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|87
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|87
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|87
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|87
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|87
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|87
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|87
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|87
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|87
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|87
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|87
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|87
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|87
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|87
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|87
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|87
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|87
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|87
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|87
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|87
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|87
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|87
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|87
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|87
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|87
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|87
144|Wound Care|Wound Care|87
145|Great presidential Moments|Great presidential Moments|87
147|(M0110) Episode Timing|(M0110) Episode Timing|87
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|87
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|87
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|87
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|87
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|87
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|87
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|87
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|87
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|87
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|87
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|87
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|87
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|87
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|87
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|87
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|87
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|87
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|87
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|87
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|87
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|87
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|87
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|87
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|87
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|87
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|87
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|87
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|87
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|87
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|87
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |87
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|87
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|87
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|87
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|87
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|87
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|87
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|87
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|87
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|87
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|87
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|87
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|87
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|87
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|87
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|87
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|87
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|87
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|87
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|87
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|87
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|87
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|87
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|87
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|87
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|87
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|87
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|87
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|87
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|87
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|87
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|87
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|87
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|87
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|87
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|87
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|87
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|87
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|87
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|87
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|87
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|87
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|87
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|87
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|87
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|87
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|87
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|87
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|87
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|87
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|87
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|87
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|87
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|87
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|87
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|87
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|87
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|87
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |87
247|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|87
248|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|87
249|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|87
250|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|87
251|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|87
252|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|87
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|88
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|88
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|88
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|88
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|88
6|(M0040) Patient First Name:|(M0040) Patient First Name:|88
7|(M0040) Patient Last Name|(M0040) Patient Last Name|88
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|88
9|(M0040) Patient Suffix|(M0040) Patient Suffix|88
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|88
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|88
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|88
13|(M0064) Social Security Number:|(M0064) Social Security Number:|88
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|88
15|(M0066) Birth Date:|(M0066) Birth Date:|88
16|(M0069) Gender:|(M0069) Gender:|88
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|88
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|88
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|88
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|88
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|88
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|88
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|88
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|88
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|88
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|88
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|88
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|88
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|88
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|88
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|88
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|88
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|88
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|88
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|88
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|88
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|88
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|88
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|88
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|88
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|88
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|88
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|88
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|88
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|88
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|88
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|88
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|88
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|88
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|88
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|88
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|88
53|(M0300) Current Residence:|(M0300) Current Residence:|88
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|88
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|88
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|88
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|88
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|88
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|88
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|88
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|88
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|88
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|88
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|88
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|88
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|88
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|88
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|88
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|88
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|88
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|88
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|88
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|88
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|88
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|88
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|88
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|88
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|88
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|88
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|88
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|88
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|88
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|88
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|88
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|88
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|88
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|88
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|88
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|88
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|88
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|88
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|88
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|88
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|88
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|88
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|88
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|88
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|88
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|88
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|88
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|88
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|88
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|88
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|88
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|88
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|88
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|88
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|88
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|88
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|88
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|88
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|88
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|88
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|88
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|88
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|88
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|88
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|88
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|88
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|88
144|Wound Care|Wound Care|88
145|Great presidential Moments|Great presidential Moments|88
147|(M0110) Episode Timing|(M0110) Episode Timing|88
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|88
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|88
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|88
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|88
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|88
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|88
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|88
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|88
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|88
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|88
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|88
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|88
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|88
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|88
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|88
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|88
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|88
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|88
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|88
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|88
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|88
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|88
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|88
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|88
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|88
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|88
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|88
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|88
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|88
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|88
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |88
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|88
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|88
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|88
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|88
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|88
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|88
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|88
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|88
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|88
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|88
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|88
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|88
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|88
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|88
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|88
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|88
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|88
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|88
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|88
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|88
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|88
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|88
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|88
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|88
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|88
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|88
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|88
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|88
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|88
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|88
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|88
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|88
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|88
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|88
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|88
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|88
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|88
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|88
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|88
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|88
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|88
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|88
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|88
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|88
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|88
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|88
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|88
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|88
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|88
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|88
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|88
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|88
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|88
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|88
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|88
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|88
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|88
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|88
243|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|88
240|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|88
241|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|88
242|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|88
346|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|89
345|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|89
344|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|89
347|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|89
318|(GG0130B3) Oral Hygiene (Dschg Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B3) Oral Hygiene (Dschg Perf): The ability to use suitable items to clean teeth. Dentures (if|89
319|(GG0130C3) Toileting Hygiene (Dschg Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C3) Toileting Hygiene (Dschg Perf): The ability to maintain perineal hygiene, adjust clothes|89
320|(GG0130E3) Shower/bathe self (Dschg Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E3) Shower/bathe self (Dschg Perf): The ability to bathe self, including washing, rinsing, an|89
321|(GG0130F3) Upper body dressing (Dschg Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F3) Upper body dressing (Dschg Perf): The ability to dress and undress above the waist;includ|89
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|89
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|89
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|89
322|(GG0130G3) Lower body dressing (Dschg Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G3) Lower body dressing (Dschg Perf): The ability to dress and undress below the waist,includ|89
323|(GG0130H3) Putting on/taking off footwear (Dschg Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H3) Putting on/taking off footwear (Dschg Perf): The ability to put on and take off socks and|89
324|(GG0170A3) Roll left and right (Dschg Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A3) Roll left and right (Dschg Perf): The ability to roll from lying on back to left and righ|89
325|(GG0170B3) Sit to lying (Dschg Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B3) Sit to lying (Dschg Perf): The ability to move from sitting on side of bed to lying flat|89
326|(GG0170C3) Lying to sitting on side of bed (Dschg Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C3) Lying to sitting on side of bed (Dschg Perf): The ability to move from lying on the back|89
327|(GG0170D3) Sit to stand (Dschg  Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D3) Sit to stand (Dschg  Perf): The ability to come to a standing position from sitting in a|89
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|89
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|89
328|(GG0170E3) Chair/bed-to-chair transfer (Dschg Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E3) Chair/bed-to-chair transfer (Dschg Perf): The ability to transfer to and from a bed to a|89
329|(GG0170F3) Toilet tranfer (Dschg Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F3) Toilet tranfer (Dschg Perf): The ability to get on and off a toilet or commode.|89
330|(GG0170G3) Car Transfer (Dschg Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G3) Car Transfer (Dschg Perf): The ability to transfer in and out of a car or van on the pass|89
331|(GG0170I3) Walk 10 feet (Dschg Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I3) Walk 10 feet (Dschg Perf): Once standing, the ability to walk at least 10 feet in a room,|89
332|(GG0170J3) Walk 50 feet with two turns (Dschg Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J3) Walk 50 feet with two turns (Dschg Perf): Once standing, the ability to walk 50 feet and|89
333|(GG0170K3) Walk 150 feet (Dschg Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K3) Walk 150 feet (Dschg Perf): Once standing, the ability to walk at least 150 feet in a cor|89
334|(GG0170L3) Walking 10 feet on uneven surfaces (Dschg Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L3) Walking 10 feet on uneven surfaces (Dschg Perf): The ability to walk 10 feet on uneven or|89
335|(GG0170M3) 1 step (curb) (Dschg Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M3) 1 step (curb) (Dschg Perf): The ability to go up and down a curb and/or up and down one s|89
336|(GG0170N3) 4 steps (Dschg Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N3) 4 steps (Dschg Perf): The ability to go up and down four steps with or without a rail. (I|89
337|(GG0170O3) 12 steps (Dschg Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O3) 12 steps (Dschg Perf): The ability to go up and down 12 steps with or without a rail.|89
338|(GG0170P3) Picking up object (Dschg Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P3) Picking up object (Dschg Perf): The ability to bend/stoop from a standing position to pic|89
339|(GG0170Q3) Does patient use wheelchair and/or scooter?|(GG0170Q3) Does patient use wheelchair and/or scooter?|89
340|(GG0170R3) Wheel 50 feet with two turns (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R3) Wheel 50 feet with two turns (Dschg Perf): Once seated in wheelchair/scooter, the ability|89
341|(GG0170RR3) Indicate the type of wheelchair or scooter used.|(GG0170RR3) Indicate the type of wheelchair or scooter used.|89
53|(M0300) Current Residence:|(M0300) Current Residence:|89
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|89
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|89
342|(GG0170S3) Wheel 150 feet (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S3) Wheel 150 feet (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at l|89
343|(GG0170SS3) Indicate the type of wheelchair or scooter used.|(GG0170SS3) Indicate the type of wheelchair or scooter used.|89
317|(GG0130A3) Eating (Dschg Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A3) Eating (Dschg Perf): The ability to use suitable utensils to bring food and/or liquid to|89
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|89
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|89
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|89
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|89
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|89
6|(M0040) Patient First Name:|(M0040) Patient First Name:|89
7|(M0040) Patient Last Name|(M0040) Patient Last Name|89
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|89
9|(M0040) Patient Suffix|(M0040) Patient Suffix|89
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|89
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|89
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|89
13|(M0064) Social Security Number:|(M0064) Social Security Number:|89
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|89
15|(M0066) Birth Date:|(M0066) Birth Date:|89
16|(M0069) Gender:|(M0069) Gender:|89
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|89
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|89
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|89
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|89
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|89
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|89
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|89
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|89
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|89
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|89
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|89
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|89
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|89
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|89
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|89
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|89
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|89
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|89
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|89
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|89
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|89
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|89
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|89
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|89
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|89
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|89
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|89
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|89
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|89
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|89
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|89
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|89
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|89
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|89
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|89
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|89
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |89
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|89
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|89
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressin|89
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |89
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|89
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|89
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|89
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|89
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|89
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|89
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|89
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|89
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|89
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|89
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|89
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|89
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|89
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|89
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|89
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|89
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|89
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|89
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|89
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|89
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|89
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|89
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|89
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|89
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|89
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|89
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|89
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|89
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|89
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|89
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|89
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|89
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|89
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |89
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|89
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|89
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|89
132|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |89
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|89
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|89
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0906 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|89
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|89
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|89
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|89
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|89
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|89
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|89
144|Wound Care|Wound Care|89
145|Great presidential Moments|Great presidential Moments|89
147|(M0110) Episode Timing|(M0110) Episode Timing|89
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|89
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|89
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|89
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|89
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|89
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|89
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|89
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|89
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|89
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|89
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|89
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|89
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|89
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|89
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|89
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|89
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|89
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|89
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|89
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|89
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|89
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|89
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|89
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|89
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|89
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|89
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|89
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|89
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|89
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|89
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|89
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|89
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|89
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|89
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|89
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|89
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|89
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|89
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|89
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|89
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|89
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|89
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|89
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|89
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|89
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|89
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|89
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|89
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|89
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|89
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|89
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|89
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|89
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|89
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|89
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|89
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|89
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|89
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|89
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|89
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|89
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|89
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|89
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|89
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|89
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|89
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|89
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|89
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|89
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|89
258|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|89
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|89
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|89
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|89
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|89
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|89
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|89
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|89
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|89
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|89
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|89
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|89
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |89
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |89
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|89
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |89
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|89
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|89
253|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|89
254|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|89
255|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|89
256|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|89
257|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|89
263|(M13072D) Date that  Stage 2 Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|89
300|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 2) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 2, enter 0.|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of |89
301|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 3) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 3, enter 0.|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of curr|89
302|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 4) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 4, enter 0.|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of curr|89
303|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to non-removable dressing|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to |89
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|89
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|89
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|89
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|89
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|89
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|89
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|89
315|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were at a Stage 1 or 2 at the most recent SOC/ROC.|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were|89
316|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury in evolution.|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury|89
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|89
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|89
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|89
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|89
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|89
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|89
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|89
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|89
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|89
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|91
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|91
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|91
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|91
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|91
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|91
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|91
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|91
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|91
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|91
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|91
292|Treatment Plan Data - Set 999 lookup|Treatment Plan Data - Set 999 lookup|91
304|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|91
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|91
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|91
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|91
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|91
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|91
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|91
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|91
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|91
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|91
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|91
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|91
6|(M0040) Patient First Name:|(M0040) Patient First Name:|91
7|(M0040) Patient Last Name|(M0040) Patient Last Name|91
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|91
9|(M0040) Patient Suffix|(M0040) Patient Suffix|91
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|91
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|91
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|91
13|(M0064) Social Security Number:|(M0064) Social Security Number:|91
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|91
15|(M0066) Birth Date:|(M0066) Birth Date:|91
16|(M0069) Gender:|(M0069) Gender:|91
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|91
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|91
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|91
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|91
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|91
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|91
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|91
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|91
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|91
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|91
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|91
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|91
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|91
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|91
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|91
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|91
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|91
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|91
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|91
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|91
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|91
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|91
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|91
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|91
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|91
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|91
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|91
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|91
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|91
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|91
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|91
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|91
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|91
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|91
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|91
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|91
53|(M0300) Current Residence:|(M0300) Current Residence:|91
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|91
317|(GG0170C1) Lying to Sitting on Side of Bed (SOC/ROC Perf): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |91
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply|91
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|91
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|91
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|91
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|91
318|(GG0170C2) Lying to Sitting on Side of Bed (Dschg Goal): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |91
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|91
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|91
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|91
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|91
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|91
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|91
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|91
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|91
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|91
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|91
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|91
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |91
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|91
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|91
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|91
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |91
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|91
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|91
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|91
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|91
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|91
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|91
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|91
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|91
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|91
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|91
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|91
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|91
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|91
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|91
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|91
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|91
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|91
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|91
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|91
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|91
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|91
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|91
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|91
329|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes|91
330|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing,|91
319|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Self Care: Code the patient¼s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illnesss, exacerbation, or injury.|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability |91
320|(GG0100B) Prior Functioning (Ambulation): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Indoor Mobility (Ambulation): Code the patient¼s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.|(GG0100B) Prior Functioning (Ambulation): Everyday Activities: Indicate the patient¼s usual ability|91
321|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Stairs: Code the patient¼s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury.|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with|91
322|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Functional Cognition: Code the patient¼s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s |91
323|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,exacerbation, or injury. (Check all that apply)|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illnes|91
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|91
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|91
324|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid t|91
325|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to|91
326|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (|91
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|91
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|91
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|91
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|91
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|91
327|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if|91
328|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothe|91
334|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,incl|91
331|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, an|91
332|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;incl|91
333|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;includ|91
335|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,including fasteners; does not include footwear(GG0130G) Lower body dressing: The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,includ|91
336|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks a|91
337|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and|91
338|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and ri|91
339|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and righ|91
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|91
340|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying fla|91
341|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat|91
342|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a|91
343|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a c|91
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|91
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|91
144|Wound Care|Wound Care|91
344|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to|91
345|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a|91
346|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode.|91
347|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode.|91
348|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the pa|91
349|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the pass|91
350|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.   (If coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb))|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a roo|91
351|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,|91
357|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or|91
352|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet an|91
353|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and|91
354|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a c|91
355|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a cor|91
356|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven|91
358|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one|91
359|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one s|91
360|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail.|91
361|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail.|91
362|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail.|91
363|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail.|91
364|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to p|91
365|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pic|91
366|(GG0170Q1) Does patient use wheelchair and/or scooter?|(GG0170Q1) Does patient use wheelchair and/or scooter?|91
367|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the abili|91
368|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability|91
369|(GG0170RR1) Indicate the type of wheelchair or scooter used.|(GG0170RR1) Indicate the type of wheelchair or scooter used.|91
370|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at|91
372|(GG0170SS1) Indicate the type of wheelchair or scooter used.|(GG0170SS1) Indicate the type of wheelchair or scooter used.|91
371|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at l|91
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|91
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|91
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|91
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|91
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|91
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|91
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|91
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|91
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|91
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|91
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|91
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|91
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|91
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|91
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|91
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|91
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|91
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|91
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|91
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|91
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|91
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|91
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|91
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|91
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|91
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|91
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|91
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|91
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|91
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|91
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|91
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|91
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|91
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|91
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|91
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|91
145|Great presidential Moments|Great presidential Moments|91
147|(M0110) Episode Timing|(M0110) Episode Timing|91
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|91
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|91
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|91
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|91
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|91
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|91
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|91
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|91
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|91
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|91
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|91
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|91
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|91
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|91
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|91
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|91
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|91
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|91
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|91
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|91
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|91
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|91
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|91
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|91
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|91
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|91
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|91
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|91
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|91
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|91
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|91
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|91
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|91
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|91
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|91
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|91
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|91
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|91
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|91
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|91
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|91
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|91
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|91
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|91
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|91
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|91
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|91
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|91
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|91
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|91
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|91
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|91
365|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P2) Picking up object (Dschg Goal): The ability to bend/stoop from a standing position to pic|93
364|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P1) Picking up object (SOC/ROC Perf): The ability to bend/stoop from a standing position to p|93
363|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O2) 12 steps (Dschg Goal): The ability to go up and down 12 steps with or without a rail.|93
362|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O1) 12 steps (SOC/ROC Perf): The ability to go up and down 12 steps with or without a rail.|93
361|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N2) 4 steps (Dschg Goal): The ability to go up and down four steps with or without a rail.|93
360|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N1) 4 steps (SOC/ROC Perf): The ability to go up and down four steps with or without a rail.|93
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|93
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|93
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|93
359|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170M2) 1 step (curb) (Dschg Goal): The ability to go up and down a curb and/or up and down one s|93
358|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M1) 1 step (curb) (SOC/ROC Perf): The ability to go up and down a curb and/or up and down one|93
356|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L1) Walking 10 feet on uneven surfaces (SOC/ROC Perf): The ability to walk 10 feet on uneven|93
355|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K2) Walk 150 feet (Dschg Goal): Once standing, the ability to walk at least 150 feet in a cor|93
354|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K1) Walk 150 feet (SOC/ROC Perf): Once standing, the ability to walk at least 150 feet in a c|93
353|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J2) Walk 50 feet with two turns (Dschg Goal): Once standing, the ability to walk 50 feet and|93
352|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J1) Walk 50 feet with two turns (SOC/ROC Perf): Once standing, the ability to walk 50 feet an|93
357|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L2) Walking 10 feet on uneven surfaces (Dschg Goal): The ability to walk 10 feet on uneven or|93
351|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I2) Walk 10 feet (Dschg Goal): Once standing, the ability to walk at least 10 feet in a room,|93
350|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.  (If coded 07, 09, 10 or 88, skip to GG0170M, 1 step (curb))|(GG0170I1) Walk 10 feet (SOC/ROC Perf): Once standing, the ability to walk at least 10 feet in a roo|93
349|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G2) Car Transfer (Dschg Goal): The ability to transfer in and out of a car or van on the pass|93
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|93
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|93
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|93
348|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G1) Car Transfer (SOC/ROC Perf): The ability to transfer in and out of a car or van on the pa|93
347|(GG0170F2) Toilet transfer (Dschg Goal): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F2) Toilet tranfer (Dschg Goal): The ability to get on and off a toilet or commode.|93
346|(GG0170F1) Toilet transfer (SOC/ROC Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F1) Toilet tranfer (SOC/ROC Perf): The ability to get on and off a toilet or commode.|93
345|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E2) Chair/bed-to-chair transfer (Dschg Goal): The ability to transfer to and from a bed to a|93
344|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E1) Chair/bed-to-chair transfer (SOC/ROC Perf): The ability to transfer to and from a bed to|93
343|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D2) Sit to stand (Dschg Goal): The ability to come to a standing position from sitting in a c|93
342|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D1) Sit to stand (SOC/ROC Perf): The ability to come to a standing position from sitting in a|93
341|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B2) Sit to lying (Dschg Goal): The ability to move from sitting on side of bed to lying flat|93
340|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B1) Sit to lying (SOC/ROC Perf): The ability to move from sitting on side of bed to lying fla|93
339|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A2) Roll left and right (Dschg Goal): The ability to roll from lying on back to left and righ|93
338|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A1) Roll left and right (SOC/ROC Perf): The ability to roll from lying on back to left and ri|93
337|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H2) Putting on/taking off footwear (Dschg Goal): The ability to put on and take off socks and|93
336|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H1) Putting on/taking off footwear (SOC/ROC Perf): The ability to put on and take off socks a|93
335|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,including fasteners; does not include footwear Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G2) Lower body dressing (Dschg Goal): The ability to dress and undress below the waist,includ|93
333|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F2) Upper body dressing (Dschg Goal): The ability to dress and undress above the waist;includ|93
334|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G1) Lower body dressing (SOC/ROC Perf): The ability to dress and undress below the waist,incl|93
332|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F1) Upper body dressing (SOC/ROC Perf): The ability to dress and undress above the waist;incl|93
331|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E2) Shower/bathe self (Dschg Goal): The ability to bathe self, including washing, rinsing, an|93
330|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E1) Shower/bathe self (SOC/ROC Perf): The ability to bathe self, including washing, rinsing,|93
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|93
327|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B2) Oral Hygiene (Dschg Goal): The ability to use suitable items to clean teeth. Dentures (if|93
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|93
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|93
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|93
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|93
326|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B1) Oral Hygiene (SOC/ROC Perf): The ability to use suitable items to clean teeth. Dentures (|93
328|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C1) Toileting Hygiene (SOC/ROC Perf): The ability to maintain perineal hygiene, adjust clothe|93
325|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A2) Eating (Dschg Goal): The ability to use suitable utensils to bring food and/or liquid to|93
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|93
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|93
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|93
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|93
324|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A1) Eating (SOC/ROC Perf): The ability to use suitable utensils to bring food and/or liquid t|93
323|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illness,exacerbation, or injury. (Check all that apply)|(GG0110) Prior Device Use. Indicate devices and aids used by the patient prior to the current illnes|93
322|(GG0100D) Prior Functioning (Funtional Cognition): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Functional Cognition: Code the patient¼s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.|(GG0100D) Prior Functioning (Functional Cognition): Everyday Activities: Indicate the patient¼s |93
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|93
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|93
321|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Stairs: Code the patient¼s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation or injury.|(GG0100C) Prior Functioning (Stairs): Everyday Activities: Indicate the patient¼s usual ability with|93
320|(GG0100B) Prior Functioning (Indoor Mobility - Ambulation): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Indoor Mobility (Ambulation): Code the patient¼s need for assistance with walking from room to room (with or without a device such as cane, crutch or walker) prior to the current illness, exacerbation, or injury.|(GG0100B) Prior Functioning (Indoor Mobility - Ambulation): Everyday Activities: Indicate the |93
319|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability with everyday activities prior to the current illness, exacerbation, or injury - Self Care: Code the patient¼s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illnesss, exacerbation, or injury.|(GG0100A) Prior Functioning (Self Care): Everyday Activities: Indicate the patient¼s usual ability|93
329|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C2) Toileting Hygiene (Dschg Goal): The ability to maintain perineal hygiene, adjust clothes|93
318|(GG0170C2) Lying to Sitting on Side of Bed (Dschg Goal): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C2) Mobility - Discharge Goal:Lying to Sitting on Side of Bed:The ability to safely move |93
314|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060B) Weight (in pounds) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|93
313|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up|(M1060A) Height (in inches) - While measuring, if the number is X.1 - X.4 round down; X.5 or greater|93
312|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions - Check all that apply.  See OASIS Guidance Manual for a complete list of relevant ICD-10 codes.|(M1028) Active Diagnoses- Comorbidities and Co-existing Conditions v Check all that apply.  |93
317|(GG0170C1) Lying to Sitting on Side of Bed (SOC/ROC Perf): The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support  Code the patient's usual performance at the SOC/ROC using the 6-point scale. If activity was not attempted at SOC/ROC, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C1) Mobility SOC/ROC performance:Lying to Sitting on Side of Bed:The ability to safely move |93
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|93
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|93
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|93
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|93
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|93
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|93
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|93
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|93
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|93
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|93
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|93
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|93
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|93
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|93
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|93
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|93
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|93
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|93
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|93
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|93
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|93
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|93
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|93
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|93
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited |93
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|93
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|93
199|(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? |(M2001) Drug Regimen Review: Did a complete drug regimen review identify potential clinically signif|93
200|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?|(M2003) Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight|93
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|93
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|93
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|93
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|93
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|93
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|93
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|93
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|93
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|93
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|93
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|93
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|93
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|93
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|93
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|93
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|93
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|93
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|93
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|93
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|93
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|93
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|93
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|93
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|93
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|93
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|93
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|93
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|93
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|93
261|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care)|93
265|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|93
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|93
306|(M2102B) ADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|93
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|93
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|93
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|93
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|93
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|93
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|93
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|93
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|93
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|93
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|93
6|(M0040) Patient First Name:|(M0040) Patient First Name:|93
7|(M0040) Patient Last Name|(M0040) Patient Last Name|93
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|93
9|(M0040) Patient Suffix|(M0040) Patient Suffix|93
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|93
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|93
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|93
13|(M0064) Social Security Number:|(M0064) Social Security Number:|93
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|93
15|(M0066) Birth Date:|(M0066) Birth Date:|93
16|(M0069) Gender:|(M0069) Gender:|93
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|93
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|93
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|93
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|93
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|93
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|93
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|93
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|93
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|93
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|93
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|93
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|93
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|93
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|93
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|93
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|93
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|93
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|93
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|93
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|93
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|93
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|93
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|93
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|93
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|93
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|93
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|93
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|93
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|93
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|93
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|93
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|93
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|93
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|93
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|93
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|93
53|(M0300) Current Residence:|(M0300) Current Residence:|93
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|93
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|93
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|93
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|93
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|93
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|93
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|93
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|93
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|93
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|93
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|93
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|93
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |93
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|93
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|93
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|93
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Unstageable:(Enter '0'|93
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|93
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|93
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|93
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|93
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|93
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|93
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|93
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|93
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|93
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|93
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|93
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|93
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|93
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|93
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|93
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|93
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|93
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|93
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|93
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|93
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|93
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|93
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|93
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|93
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|93
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|93
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|93
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|93
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|93
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|93
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|93
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|93
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|93
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|93
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|93
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|93
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|93
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|93
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|93
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|93
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|93
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|93
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|93
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|93
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|93
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|93
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|93
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|93
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|93
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|93
144|Wound Care|Wound Care|93
145|Great presidential Moments|Great presidential Moments|93
147|(M0110) Episode Timing|(M0110) Episode Timing|93
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|93
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|93
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|93
371|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S2) Wheel 150 feet (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at l|93
372|(GG0170SS1) Indicate the type of wheelchair or scooter used.|(GG0170SS1) Indicate the type of wheelchair or scooter used.|93
370|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S1) Wheel 150 feet (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at|93
369|(GG0170RR1) Indicate the type of wheelchair or scooter used.|(GG0170RR1) Indicate the type of wheelchair or scooter used.|93
368|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R2) Wheel 50 feet with two turns (Dschg Goal): Once seated in wheelchair/scooter, the ability|93
367|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R1) Wheel 50 feet with two turns (SOC/ROC Perf): Once seated in wheelchair/scooter, the abili|93
366|(GG0170Q1) Does patient use wheelchair and/or scooter?|(GG0170Q1) Does patient use wheelchair and/or scooter?|93
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|93
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|93
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|93
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|93
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|94
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|94
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|94
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|94
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|94
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|94
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|94
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|94
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|94
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|94
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|94
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|94
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|94
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|94
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|94
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|94
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|94
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|94
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|94
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|94
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|94
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|94
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|94
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|94
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|94
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|94
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|94
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|94
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|94
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|94
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|94
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|94
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|94
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|94
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|94
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|94
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|94
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|94
53|(M0300) Current Residence:|(M0300) Current Residence:|94
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|94
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|94
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|94
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|94
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|94
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|94
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|94
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|94
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|94
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|94
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|94
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|94
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |94
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|94
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|94
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|94
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |94
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|94
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|94
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|94
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|94
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|94
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|94
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|94
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|94
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|94
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|94
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|94
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|94
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|94
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|94
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|94
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|94
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|94
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|94
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|94
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|94
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|94
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|94
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|94
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|94
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|94
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|94
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|94
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|94
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|94
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|94
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|94
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|94
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|94
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|94
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|94
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|94
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|94
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|94
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|94
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|94
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|94
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|94
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|94
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|94
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|94
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|94
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|94
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|94
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|94
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|94
144|Wound Care|Wound Care|94
145|Great presidential Moments|Great presidential Moments|94
147|(M0110) Episode Timing|(M0110) Episode Timing|94
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|94
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|94
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|94
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|94
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|94
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|94
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|94
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|94
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|94
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|94
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|94
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|94
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|94
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|94
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|94
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|94
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|94
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|94
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|94
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|94
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|94
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|94
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|94
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|94
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|94
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|94
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|94
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|94
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|94
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|94
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|94
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|94
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|94
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|94
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|94
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|94
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|94
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|94
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|94
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|94
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|94
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|94
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|94
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|94
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|94
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|94
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|94
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|94
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|94
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|94
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|94
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|94
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|94
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|94
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|94
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|94
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|94
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|94
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|94
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|94
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|94
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|94
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|94
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|94
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|94
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|94
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|94
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|94
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|94
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|94
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|94
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|94
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|94
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|94
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|94
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|94
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|94
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|94
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |94
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |94
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|94
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |94
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|94
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|94
239||(M1005) UK - Inpatient Discharge Date Unknown|94
262|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|94
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|94
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|94
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|94
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|94
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|94
6|(M0040) Patient First Name:|(M0040) Patient First Name:|94
7|(M0040) Patient Last Name|(M0040) Patient Last Name|94
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|94
9|(M0040) Patient Suffix|(M0040) Patient Suffix|94
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|94
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|94
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|94
13|(M0064) Social Security Number:|(M0064) Social Security Number:|94
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|94
15|(M0066) Birth Date:|(M0066) Birth Date:|94
16|(M0069) Gender:|(M0069) Gender:|94
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|94
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|94
263|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid|94
264|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures|94
265|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clot|94
266|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and|94
277|(GG0170Q4) Does patient use wheelchair and/or scooter?|(GG0170Q4) Does patient use wheelchair and/or scooter?|94
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|94
268|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the b|94
269|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in|94
270|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed t|94
271|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode.|94
272|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a r|94
273|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet|94
274|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneve|94
275|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170Q, Does patient usewheelchair and/or scooter?)|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down o|94
276|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail|94
278|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the abi|94
42|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|(M1023) e. Other Diagnosis:  ICD Code - Case Mix|95
43|(M1023) e. Other Diagnosis:  Symptom Control Rating|(M1023) e. Other Diagnosis:  Symptom Control Rating|95
44|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|(M1023) f. Other Diagnosis:  ICD Code - Case Mix|95
276|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170N4) 4 steps (Follow-Up Perf): The ability to go up and down four steps with or without a rail|95
274|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L4) Walking 10 feet on uneven surfaces (Follow-Up Perf): The ability to walk 10 feet on uneve|95
273|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J4) Walk 50 feet with two turns (Follow-Up Perf): Once standing, the ability to walk 50 feet|95
272|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I4) Walk 10 feet (Follow-Up Perf): Once standing, the ability to walk at least 10 feet in a r|95
271|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F4) Toilet transfer (Follow-Up Perf): The ability to get on and off a toilet or commode.|95
270|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E4) Chair/bed-to-chair transfer (Follow-Up Perf): The ability to transfer to and from a bed t|95
269|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D4) Sit to stand (Follow-Up Perf): The ability to come to a standing position from sitting in|95
268|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C4) Lying to sitting on side of bed (Follow-Up Perf): The ability to move from lying on the b|95
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|95
266|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A4) Roll left and right (Follow-Up Perf): The ability to roll from lying on back to left and|95
275|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down one step.  Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.(If coded 07, 09, 10 or 88, skip to GG0170Q, Does patient usewheelchair and/or scooter?)|(GG0170M4) 1 step (curb) (Follow-Up Perf): The ability to go up and down a curb and/or up and down o|95
277|(GG0170Q4) Does patient use wheelchair and/or scooter?|(GG0170Q4) Does patient use wheelchair and/or scooter?|95
45|(M1023) f. Other Diagnosis:   Symptom Control Rating|(M1023) f. Other Diagnosis:   Symptom Control Rating|95
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|95
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|95
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|95
278|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R4) Wheel 50 feet with two turns (Follow-Up Perf): Once seated in wheelchair/scooter, the abi|95
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|95
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|95
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|95
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|95
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|95
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|95
265|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C4) Toileting Hygiene (Follow-Up Perf): The ability to maintain perineal hygiene, adjust clot|95
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|95
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|95
264|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B4) Oral Hygiene (Follow-Up Perf): The ability to use suitable items to clean teeth. Dentures|95
263|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A4) Eating (Follow-Up Perf): The ability to use suitable utensils to bring food and/or liquid|95
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|95
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|95
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|95
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|95
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|95
6|(M0040) Patient First Name:|(M0040) Patient First Name:|95
7|(M0040) Patient Last Name|(M0040) Patient Last Name|95
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|95
9|(M0040) Patient Suffix|(M0040) Patient Suffix|95
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|95
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|95
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|95
13|(M0064) Social Security Number:|(M0064) Social Security Number:|95
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|95
15|(M0066) Birth Date:|(M0066) Birth Date:|95
16|(M0069) Gender:|(M0069) Gender:|95
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|95
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|95
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|95
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|95
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|95
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|95
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|95
28|(M1017) a. Changed Medical Regimen ICD1|(M1017) a. Changed Medical Regimen ICD1|95
29|(M1017) b. Changed Medical Regimen ICD2|(M1017) b. Changed Medical Regimen ICD2|95
30|(M1017) c. Changed Medical Regimen ICD3|(M1017) c. Changed Medical Regimen ICD3|95
31|(M1017) d. Changed Medical Regimen ICD4|(M1017) d. Changed Medical Regimen ICD4|95
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|95
33|(M1021)  Primary Diagnosis:  ICD - Case Mix|(M1021)  Primary Diagnosis:  ICD - Case Mix|95
34|(M1021)  Primary Diagnosis:  Symptom Control Rating|(M1021)  Primary Diagnosis:  Symptom Control Rating|95
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|95
36|(M1023) b. Other Diagnosis:  ICD - Case Mix|(M1023) b. Other Diagnosis:  ICD - Case Mix|95
37|(M1023) b. Other Diagnosis:  Symptom Control Rating|(M1023) b. Other Diagnosis:  Symptom Control Rating|95
38|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|(M1023) c. Other Diagnosis:  ICD Code - Case Mix|95
39|(M1023) c. Other Diagnosis:  Symptom Control Rating|(M1023) c. Other Diagnosis:  Symptom Control Rating|95
40|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|(M1023) d. Other Diagnosis:  ICD Code - Case Mix|95
41|(M1023) d. Other Diagnosis:  Symptom Control Rating|(M1023) d. Other Diagnosis:  Symptom Control Rating|95
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|95
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|95
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|95
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|95
53|(M0300) Current Residence:|(M0300) Current Residence:|95
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|95
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |95
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|95
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|95
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|95
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |95
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|95
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|95
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|95
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|95
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|95
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|95
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|95
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|95
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|95
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|95
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|95
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|95
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|95
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|95
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|95
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|95
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|95
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|95
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|95
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|95
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|95
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|95
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|95
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|95
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|95
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|95
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|95
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|95
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|95
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|95
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|95
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|95
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|95
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|95
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|95
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|95
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|95
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|95
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|95
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|95
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|95
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|95
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|95
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|95
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|95
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|95
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|95
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|95
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|95
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|95
144|Wound Care|Wound Care|95
145|Great presidential Moments|Great presidential Moments|95
147|(M0110) Episode Timing|(M0110) Episode Timing|95
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|95
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|95
150|(M1025A3) Payment  Diagnosis: Primary, Column 3|(M1025A3) Payment  Diagnosis: Primary, Column 3|95
151|(M1025B3) Payment  Diagnosis First Secondary, Column 3|(M1025B3) Payment  Diagnosis First Secondary, Column 3|95
152|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|(M1025C3) Payment Diagnosis: Second Secondary, Column 3|95
153|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|(M1025D3) Payment Diagnosis:Third Secondary, Column 3|95
154|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1025E3) Payment Diagnosis: Fourth Secondary, Column 3|95
155|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1025F3) Payment Diagnosis: Fifth Secondary, Column 3|95
156|(M1025A4) Payment Diagnosis: Primary, Column 4|(M1025A4) Payment Diagnosis: Primary, Column 4|95
157|(M1025B4) Payment Diagnosis: First Secondary, Column 4|(M1025B4) Payment Diagnosis: First Secondary, Column 4|95
158|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|(M1025C4) Payment Diagnosis: Second Secondary, Column 4|95
159|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|(M1025D4) Payment Diagnosis: Third Secondary, Column 4|95
160|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1025E4) Payment Diagnosis: Fourth Secondary, Column 4|95
161|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1025F4) Payment Diagnosis: Fifth Secondary, Column 4|95
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|95
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|95
164|(M1017) e. Changed Medical Regimen ICD5|(M1017) e. Changed Medical Regimen ICD5|95
166|(M1017) f. Changed Medical Regimen ICD6|(M1017) f. Changed Medical Regimen ICD6|95
168|(M1011) c. Inpatient Facility ICD3|(M1011) c. Inpatient Facility ICD3|95
169|(M1011) d. Inpatient Facility ICD4|(M1011) d. Inpatient Facility ICD4|95
170|(M1011) e. Inpatient Facility ICD5|(M1011) e. Inpatient Facility ICD5|95
171|(M1011) f.  Inpatient Facility ICD6|(M1011) f.  Inpatient Facility ICD6|95
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|95
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|95
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|95
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|95
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|95
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|95
178|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|95
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|95
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|95
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|95
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|95
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|95
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|95
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|95
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|95
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|95
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|95
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|95
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV  pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|95
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|95
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|95
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|95
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|95
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|95
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|95
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|95
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|95
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|95
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|95
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|95
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|95
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|95
204|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1017)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|95
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|95
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|95
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|95
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|95
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|95
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|95
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|95
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|95
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|95
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|95
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|95
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|95
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|95
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|95
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|95
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|95
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|95
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|95
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|95
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|95
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|95
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|95
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|95
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|95
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|95
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|95
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|95
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |95
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |95
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|95
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |95
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most rec|95
259|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most rece|95
260|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|95
261|(M1011) NA - Inpatient stay within last 14 days|(M1011) NA - Inpatient stay within last 14 days|95
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|95
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|95
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|95
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|95
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|95
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|95
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|95
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|96
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|96
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|96
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|96
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|96
6|(M0040) Patient First Name:|(M0040) Patient First Name:|96
7|(M0040) Patient Last Name|(M0040) Patient Last Name|96
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|96
9|(M0040) Patient Suffix|(M0040) Patient Suffix|96
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|96
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|96
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|96
13|(M0064) Social Security Number:|(M0064) Social Security Number:|96
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|96
15|(M0066) Birth Date:|(M0066) Birth Date:|96
16|(M0069) Gender:|(M0069) Gender:|96
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|96
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|96
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|96
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|96
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|96
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|96
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|96
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|96
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|96
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|96
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|96
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|96
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|96
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|96
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|96
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|96
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|96
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|96
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|96
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|96
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|96
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|96
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|96
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|96
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|96
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|96
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|96
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|96
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|96
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|96
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|96
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|96
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|96
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|96
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|96
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|96
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|96
53|(M0300) Current Residence:|(M0300) Current Residence:|96
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|96
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|96
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|96
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|96
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|96
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|96
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|96
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|96
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|96
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|96
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|96
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|96
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|96
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|96
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|96
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|96
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|96
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|96
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|96
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|96
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|96
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|96
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|96
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|96
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|96
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|96
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|96
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|96
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|96
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|96
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|96
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|96
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|96
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|96
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|96
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|96
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|96
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|96
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|96
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|96
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|96
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|96
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|96
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|96
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|96
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|96
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|96
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|96
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|96
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|96
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|96
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|96
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|96
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|96
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|96
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|96
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|96
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|96
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|96
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|96
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|96
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|96
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|96
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|96
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|96
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|96
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|96
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go to M0903 ]|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)  [ Go|96
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|96
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|96
144|Wound Care|Wound Care|96
145|Great presidential Moments|Great presidential Moments|96
147|(M0110) Episode Timing|(M0110) Episode Timing|96
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|96
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|96
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|96
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|96
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|96
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|96
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|96
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|96
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|96
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|96
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|96
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|96
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|96
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|96
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|96
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|96
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|96
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|96
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|96
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|96
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|96
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|96
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|96
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|96
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|96
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|96
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |96
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|96
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|96
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|96
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|96
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|96
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|96
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|96
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|96
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|96
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|96
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|96
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|96
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|96
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|96
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|96
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|96
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|96
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|96
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|96
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|96
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|96
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|96
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|96
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|96
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|96
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|96
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|96
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|96
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|96
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|96
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|96
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|96
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|96
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|96
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|96
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|96
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|96
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|96
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|96
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|96
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|96
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|96
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|96
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|96
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|96
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|96
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|96
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|96
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|96
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|96
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|96
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|96
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|96
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|96
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|96
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|96
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|96
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |96
241|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|96
242|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|96
243|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|96
244|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|96
245|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|96
246|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|96
250|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|96
247|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|96
248|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|96
249|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|96
255|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|97
254|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|97
253|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|97
256|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|97
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|97
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|97
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|97
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|97
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|97
6|(M0040) Patient First Name:|(M0040) Patient First Name:|97
7|(M0040) Patient Last Name|(M0040) Patient Last Name|97
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|97
9|(M0040) Patient Suffix|(M0040) Patient Suffix|97
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|97
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|97
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|97
13|(M0064) Social Security Number:|(M0064) Social Security Number:|97
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|97
15|(M0066) Birth Date:|(M0066) Birth Date:|97
16|(M0069) Gender:|(M0069) Gender:|97
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|97
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|97
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|97
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|97
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|97
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|97
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|97
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|97
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|97
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|97
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|97
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|97
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|97
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|97
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|97
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|97
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|97
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|97
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|97
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|97
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|97
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|97
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|97
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|97
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|97
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|97
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|97
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|97
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|97
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|97
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|97
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|97
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|97
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|97
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|97
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|97
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|97
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|97
53|(M0300) Current Residence:|(M0300) Current Residence:|97
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|97
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|97
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|97
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|97
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|97
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|97
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|97
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|97
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|97
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|97
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|97
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|97
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|97
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|97
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|97
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|97
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|97
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|97
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|97
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|97
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|97
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|97
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|97
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|97
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|97
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|97
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|97
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|97
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|97
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|97
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|97
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|97
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|97
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|97
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|97
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|97
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|97
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|97
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|97
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|97
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|97
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|97
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|97
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|97
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|97
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|97
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|97
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|97
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|97
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|97
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|97
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|97
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|97
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|97
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|97
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|97
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|97
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|97
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|97
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|97
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|97
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.) [ Go to M0903 ]|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|97
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go to M0903|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.) [ Go|97
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|97
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|97
144|Wound Care|Wound Care|97
145|Great presidential Moments|Great presidential Moments|97
147|(M0110) Episode Timing|(M0110) Episode Timing|97
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|97
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|97
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|97
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|97
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|97
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|97
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|97
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|97
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|97
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|97
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|97
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|97
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|97
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|97
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|97
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|97
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|97
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|97
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|97
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|97
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|97
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|97
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|97
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|97
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|97
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|97
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|97
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|97
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|97
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|97
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |97
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|97
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|97
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|97
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|97
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|97
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|97
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|97
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|97
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|97
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|97
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|97
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|97
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|97
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|97
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|97
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|97
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|97
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|97
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|97
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|97
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|97
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|97
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|97
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|97
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|97
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|97
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|97
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|97
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|97
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|97
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|97
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|97
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|97
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|97
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|97
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|97
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|97
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|97
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|97
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|97
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|97
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|97
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|97
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|97
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|97
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|97
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|97
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|97
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|97
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|97
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|97
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|97
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|97
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|97
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|97
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|97
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|97
239|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |97
247|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|97
248|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|97
249|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|97
250|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|97
251|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|97
252|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|97
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|98
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|98
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|98
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|98
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|98
6|(M0040) Patient First Name:|(M0040) Patient First Name:|98
7|(M0040) Patient Last Name|(M0040) Patient Last Name|98
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|98
9|(M0040) Patient Suffix|(M0040) Patient Suffix|98
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|98
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|98
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|98
13|(M0064) Social Security Number:|(M0064) Social Security Number:|98
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|98
15|(M0066) Birth Date:|(M0066) Birth Date:|98
16|(M0069) Gender:|(M0069) Gender:|98
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|98
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|98
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|98
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|98
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|98
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|98
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|98
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|98
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|98
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|98
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|98
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|98
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|98
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|98
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|98
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|98
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|98
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|98
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|98
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|98
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|98
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|98
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|98
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|98
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|98
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|98
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|98
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|98
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|98
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|98
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|98
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|98
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|98
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|98
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|98
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|98
53|(M0300) Current Residence:|(M0300) Current Residence:|98
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|98
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|98
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|98
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|98
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|98
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|98
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|98
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|98
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|98
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|98
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|98
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|98
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II (Enter '0' if|98
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III (Enter '0' i|98
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV (Enter '0' if|98
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dress|98
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|98
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|98
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|98
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|98
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|98
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|98
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|98
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|98
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|98
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|98
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|98
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|98
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|98
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|98
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|98
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|98
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|98
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|98
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|98
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|98
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|98
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|98
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|98
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|98
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|98
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|98
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|98
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|98
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|98
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|98
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|98
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|98
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|98
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|98
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|98
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|98
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|98
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|98
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|98
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|98
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|98
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|98
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|98
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|98
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|98
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|98
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|98
138|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mark all that apply.)|(M2430) Reason for Hospitalization: For what reason(s) did the patient require hospitalization? (Mar|98
139|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M2440) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|98
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|98
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|98
144|Wound Care|Wound Care|98
145|Great presidential Moments|Great presidential Moments|98
147|(M0110) Episode Timing|(M0110) Episode Timing|98
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|98
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|98
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|98
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|98
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|98
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|98
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|98
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|98
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|98
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|98
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|98
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|98
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|98
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|98
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|98
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|98
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|98
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|98
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|98
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|98
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|98
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|98
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|98
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|98
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|98
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|98
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|98
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|98
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|98
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|98
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |98
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|98
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|98
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|98
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|98
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|98
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|98
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|98
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|98
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|98
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length (head-to-toe»|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|98
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|98
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|98
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|98
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|98
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|98
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|98
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|98
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|98
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|98
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|98
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|98
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|98
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|98
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|98
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|98
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|98
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|98
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|98
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|98
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|98
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|98
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|98
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|98
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|98
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|98
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|98
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|98
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|98
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|98
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|98
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|98
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|98
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|98
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|98
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|98
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|98
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|98
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|98
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|98
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|98
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|98
233|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II at time of most reccent SOC/ROC (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A2) Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage II, that were Stage II a|98
234|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were stage III at time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.|(M1308B2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage III, that were s|98
235|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were stage IV ar time of most recent SOC/ROC (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C2) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at  Stage IV, that were st|98
236|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device|(M1308D12) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstagebale, that were  U|98
237|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Unhealed (non-epithelialized) Pressure Ulcers Unstageable at time of most recent SOC/ROC (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|98
238|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were present Unhealed (non-epithelialized) Pressure Ulcers Unstageable at the time of most recent SOC/ROC (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|98
239|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hospital emergency department (includes holding/observation)?|(M2300) Emergent Care: Since the last time OASIS data were collected, has the patient utilized a hos|98
243|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|98
240|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|98
241|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|98
242|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|98
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|99
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|99
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|99
346|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain|(J1900B) Number of Falls Since SOC/ROC, whichever is more recent: Injury (except major): Skin tears,|99
345|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall|(J1900A) Number of Falls Since SOC/ROC, whichever is more recent: No injury: No evidence of any inju|99
344|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|(J1800) Has the patient had any falls since SOC/ROC, whichever is more recent?|99
347|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma|(J1900C) Major injury: Bone fractures, joint dislocations, closed head injuries with altered conscio|99
318|(GG0130B3) Oral Hygiene (Dschg Perf): The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to remove and replace dentures from and to the mouth,and manage equipment for soaking and rinsing them. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130B3) Oral Hygiene (Dschg Perf): The ability to use suitable items to clean teeth. Dentures (if|99
319|(GG0130C3) Toileting Hygiene (Dschg Perf): The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy,include wiping the opening but not managing equipment. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130C3) Toileting Hygiene (Dschg Perf): The ability to maintain perineal hygiene, adjust clothes|99
320|(GG0130E3) Shower/bathe self (Dschg Perf): The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130E3) Shower/bathe self (Dschg Perf): The ability to bathe self, including washing, rinsing, an|99
321|(GG0130F3) Upper body dressing (Dschg Perf): The ability to dress and undress above the waist;including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130F3) Upper body dressing (Dschg Perf): The ability to dress and undress above the waist;includ|99
25|(M1011) a. Inpatient Facility ICD1|(M1011) a. Inpatient Facility ICD1|99
26|(M1011) b. Inpatient Facility ICD2|(M1011) b. Inpatient Facility ICD2|99
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|99
322|(GG0130G3) Lower body dressing (Dschg Perf): The ability to dress and undress below the waist,including fasteners; does not include footwear. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130G3) Lower body dressing (Dschg Perf): The ability to dress and undress below the waist,includ|99
323|(GG0130H3) Putting on/taking off footwear (Dschg Perf): The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130H3) Putting on/taking off footwear (Dschg Perf): The ability to put on and take off socks and|99
324|(GG0170A3) Roll left and right (Dschg Perf): The ability to roll from lying on back to left and right side,and return to lying on back on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170A3) Roll left and right (Dschg Perf): The ability to roll from lying on back to left and righ|99
325|(GG0170B3) Sit to lying (Dschg Perf): The ability to move from sitting on side of bed to lying flat on the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170B3) Sit to lying (Dschg Perf): The ability to move from sitting on side of bed to lying flat|99
326|(GG0170C3) Lying to sitting on side of bed (Dschg Perf): The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170C3) Lying to sitting on side of bed (Dschg Perf): The ability to move from lying on the back|99
327|(GG0170D3) Sit to stand (Dschg  Perf): The ability to come to a standing position from sitting in a chair,wheelchair, or on the side of the bed. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170D3) Sit to stand (Dschg  Perf): The ability to come to a standing position from sitting in a|99
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|99
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|99
328|(GG0170E3) Chair/bed-to-chair transfer (Dschg Perf): The ability to transfer to and from a bed to a chair (or wheelchair). Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170E3) Chair/bed-to-chair transfer (Dschg Perf): The ability to transfer to and from a bed to a|99
329|(GG0170F3) Toilet tranfer (Dschg Perf): The ability to get on and off a toilet or commode. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170F3) Toilet tranfer (Dschg Perf): The ability to get on and off a toilet or commode.|99
330|(GG0170G3) Car Transfer (Dschg Perf): The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170G3) Car Transfer (Dschg Perf): The ability to transfer in and out of a car or van on the pass|99
331|(GG0170I3) Walk 10 feet (Dschg Perf): Once standing, the ability to walk at least 10 feet in a room,corridor, or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170I3) Walk 10 feet (Dschg Perf): Once standing, the ability to walk at least 10 feet in a room,|99
332|(GG0170J3) Walk 50 feet with two turns (Dschg Perf): Once standing, the ability to walk 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170J3) Walk 50 feet with two turns (Dschg Perf): Once standing, the ability to walk 50 feet and|99
333|(GG0170K3) Walk 150 feet (Dschg Perf): Once standing, the ability to walk at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170K3) Walk 150 feet (Dschg Perf): Once standing, the ability to walk at least 150 feet in a cor|99
334|(GG0170L3) Walking 10 feet on uneven surfaces (Dschg Perf): The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170L3) Walking 10 feet on uneven surfaces (Dschg Perf): The ability to walk 10 feet on uneven or|99
335|(GG0170M3) 1 step (curb) (Dschg Perf): The ability to go up and down a curb and/or up and down one step. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.)|(GG0170M3) 1 step (curb) (Dschg Perf): The ability to go up and down a curb and/or up and down one s|99
336|(GG0170N3) 4 steps (Dschg Perf): The ability to go up and down four steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices. (If coded 07, 09, 10 or 88, skip to GG0170P, Picking up object.|(GG0170N3) 4 steps (Dschg Perf): The ability to go up and down four steps with or without a rail. (I|99
337|(GG0170O3) 12 steps (Dschg Perf): The ability to go up and down 12 steps with or without a rail. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170O3) 12 steps (Dschg Perf): The ability to go up and down 12 steps with or without a rail.|99
338|(GG0170P3) Picking up object (Dschg Perf): The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170P3) Picking up object (Dschg Perf): The ability to bend/stoop from a standing position to pic|99
339|(GG0170Q3) Does patient use wheelchair and/or scooter?|(GG0170Q3) Does patient use wheelchair and/or scooter?|99
340|(GG0170R3) Wheel 50 feet with two turns (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170R3) Wheel 50 feet with two turns (Dschg Perf): Once seated in wheelchair/scooter, the ability|99
341|(GG0170RR3) Indicate the type of wheelchair or scooter used.|(GG0170RR3) Indicate the type of wheelchair or scooter used.|99
53|(M0300) Current Residence:|(M0300) Current Residence:|99
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|99
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|99
342|(GG0170S3) Wheel 150 feet (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0170S3) Wheel 150 feet (Dschg Perf): Once seated in wheelchair/scooter, the ability to wheel at l|99
343|(GG0170SS3) Indicate the type of wheelchair or scooter used.|(GG0170SS3) Indicate the type of wheelchair or scooter used.|99
317|(GG0130A3) Eating (Dschg Perf): The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient. Code the patient's usual performance using the 6-point scale. If activity was not attempted, code the reason.Coding: Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality,score according to amount of assistance provided.Activity may be completed with or without assistive devices.|(GG0130A3) Eating (Dschg Perf): The ability to use suitable utensils to bring food and/or liquid to|99
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|99
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|99
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|99
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|99
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|99
6|(M0040) Patient First Name:|(M0040) Patient First Name:|99
7|(M0040) Patient Last Name|(M0040) Patient Last Name|99
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|99
9|(M0040) Patient Suffix|(M0040) Patient Suffix|99
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|99
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|99
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|99
13|(M0064) Social Security Number:|(M0064) Social Security Number:|99
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|99
15|(M0066) Birth Date:|(M0066) Birth Date:|99
16|(M0069) Gender:|(M0069) Gender:|99
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|99
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|99
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|99
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|99
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|99
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|99
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|99
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|99
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|99
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|99
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|99
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|99
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|99
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|99
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|99
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|99
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|99
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|99
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|99
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|99
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|99
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|99
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|99
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|99
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|99
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|99
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|99
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|99
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|99
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|99
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|99
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|99
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|99
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|99
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|99
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|99
66|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers [If 0 at FU/DC Go to M1311B1]|(M1311A1) Current Number of Unhealed Pressure Ulcers at Stage 2: Partial thickness loss of dermis |99
67|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.May include undermining and tunneling. Number of Stage 3 pressure ulcers [If 0 at FU/DC Go to M1311C1]|(M1311B1) Current Number of Unhealed Pressure Ulcers at Stage 3: Full thickness tissue loss. Sub|99
68|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers[If 0 at FU/DC Go to M1311D1]|(M1311C1) Current Number of Unhealed Pressure Ulcers at Stage 4: Full thickness tissue loss with ex|99
69|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers due to non-removable dressing/device [If 0 at FU/DC Go to M1311E1]|(M1311D1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Non-removable dressin|99
70|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar [If 0 at FU/DC Go to M1311F1]|(M1311E1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Slough and/or eschar: |99
71|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable: (Excludes pressure ulcer that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar,or suspected deep tissue injury.)|(M1324) Stage of Most Problematic Unhealed Pressure Injury that is Stageable:|99
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|99
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|99
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|99
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|99
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|99
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|99
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|99
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|99
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|99
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|99
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|99
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|99
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|99
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|99
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|99
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|99
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|99
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|99
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|99
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|99
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|99
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|99
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|99
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|99
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|99
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|99
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|99
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|99
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|99
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|99
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|99
111|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Planand Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|99
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|99
123|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURENT ABILITY to prepare and take ALL prescribe|99
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|99
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|99
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|99
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|99
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|99
132|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?|(M2301) Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has |99
133|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? (Mark all that apply.)|(M2310) Reason for Emergent Care: For what reason(s) did the patient receive emergent care (with or|99
134|(M2410) To which Inpatient Facility has the patient been admitted?|(M2410) To which Inpatient Facility has the patient been admitted?|99
135|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only one answer.) [ Go to M0906 ]|(M2420) Discharge Disposition: Where is the patient after discharge from your agency? (Choose only o|99
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|99
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|99
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|99
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|99
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|99
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|99
144|Wound Care|Wound Care|99
145|Great presidential Moments|Great presidential Moments|99
147|(M0110) Episode Timing|(M0110) Episode Timing|99
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|99
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|99
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|99
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|99
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|99
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|99
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|99
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|99
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|99
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|99
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|99
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|99
160|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fourth Secondary, Column 4|99
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|99
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|99
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|99
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|99
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|99
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|99
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|99
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|99
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|99
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|99
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|99
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|99
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|99
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|99
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|99
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|99
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|99
180|(M1041) Influenza Vaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?  |(M1041) Influenza Vaccine Data Collection: Does this episode of care include dates 10-1 to 3-31 |99
181|(M1046) Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year+s flu season? |(M1046) Influenza Vaccine Received: Did patient receive flu vaccine for this year+s flu season?|99
182|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination (for example pneumovax)?|(M1051) Pneumococcal Vaccine: Has the patient ever received the pneumococcal vaccination|99
183|(M1056) Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example pneumovax) state reason: |(M1056) Reason PPV not received: If pneumococcal vacc not received state reason|99
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|99
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|99
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|99
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|99
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|99
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|99
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320.Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|99
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|99
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|99
193|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues|(M1322) Current Number of Stage I Pressure Injuries: Intact skin with non-blanchable redness|99
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|99
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|99
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|99
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|99
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|99
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|99
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|99
201|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?|(M2005) Medication Intervention: Did the agency contact and complete physician (or physician-designe|99
202|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?|(M2016) Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most|99
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|99
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|99
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|99
206|(M1307) The Oldest Non-epithelialized Stage 2 Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|99
207|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution Number of unstageable pressure ulcers with suspected deep tissue injury in evolution [ If 0 - Go to M1322 (at Follow up), Go to M1313 (at Discharge)]|(M1311F1) Current Number of Unhealed Pressure Ulcers that are Unstageable: Deep tissue injury: Susp|99
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|99
209|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a  Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|99
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|99
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|99
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|99
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|99
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|99
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|99
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|99
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|99
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|99
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|99
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|99
258|(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? f. Pressure ulcer treatment based on principles of moist wound healing |(M2401F) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|99
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|99
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|99
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|99
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|99
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|99
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|99
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|99
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|99
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|99
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|99
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|99
233|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311A2) Number of these Stage 2 pressure ulcers (from M1311A1) that were present at most |99
234|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311B2) Number of these Stage 3 pressure ulcers (from M1311B1) that were present at most recent |99
235|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311C2) Number of these Stage 4 pressure ulcers (from M1311C1) that were present at most recent SO|99
236|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1311D2) Number of these unstageable pressure ulcers (from M1311D1) that were present at most |99
237|(M1311E2) Number of these unstageable pressure ulcers (from M1311E1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D22) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were Un|99
238|(M1311F2) Number of these unstageable pressure ulcers (from M1311F1) that were present at most recent SOC/ROC - enter how many were noted at the time of most recent SOC/ROC|(M1308D32) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable, that were pr|99
253|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care|(M2401A) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|99
254|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? b. Falls prevention interventions|(M2401B) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|99
255|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? c. Depression intervention(s) such as medication, referral for other treatment,or a monitoring plan for current treatment|(M2401C) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|99
256|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? d. Intervention(s) to monitor and mitigate pain|(M2401D) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|99
257|(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? e. Intervention(s) to prevent pressure ulcers |(M2401E) Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessm|99
263|(M13072D) Date that  Stage 2 Pressure Ulcer present at discharge developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:|(M13072D) Date that  Stage II Pressure Ulcer present at discharge developed since the most recent SO|99
300|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 2) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 2, enter 0.|(M1313A) Worsening in Pressure Ulcer Status (Stage 2) since SOC/ROC:Indicate the number of |99
301|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 3) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 3, enter 0.|(M1313B) Worsening in Pressure Ulcer Status (Stage 3) since SOC/ROC:Indicate the number of curr|99
302|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of current pressure ulcers (Stage 4) that were not present or were at a lesser stage at the most recent SOC/ROC. If no current pressure ulcer at stage 4, enter 0.|(M1313C) Worsening in Pressure Ulcer Status (Stage 4) since SOC/ROC:Indicate the number of curr|99
303|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to non-removable dressing|(M1313D) Worsening in Pressure Ulcer Status since SOC/ROC: Known or likely but Unstageable due to |99
305|(M2102A) ADL assistance (for example transfer/ambulation bathing dressing toileting eating/feeding): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102A) Care mgmt types/sources: ADL|99
306|(M2102B) IADL assistance (for example meals housekeeping laundry telephone shopping finances): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102B) Care mgmt types/sources: IADL|99
307|(M2102C) Medication administration (for example oral inhaled or injectable): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102C) Care mgmt types/sources: med admin|99
308|(M2102D) Medical procedures/ treatments (for example changing wound dressing home exercise program):   : Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff |(M2102D) Care mgmt types/sources: med procs tx|99
309|(M2102E) Management of Equipment (for example oxygen IV/Infusion equipment enteral/parenteral nutrition ventilator therapy equipment or supplies): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102E) Care mgmt types/sources: equipment|99
310|(M2102F) Supervision and safety (for example due to cognitive impairment): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102F) Care mgmt types/sources: supervision and safety|99
311|(M2102G) Advocacy or facilitation of patient participation in appropriate medical care (for example transportation to or from appointments): Determine the ability and willingness of non-agency caregivers to provide assistance. Excludes all care by your agency staff|(M2102G) Care mgmt types/sources: advocacy or facilitation|99
315|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were at a Stage 1 or 2 at the most recent SOC/ROC.|(M1313E) Worsening in Pressure Ulcer Status since SOC/ROC: Report the number that are new or were|99
316|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury in evolution.|(M1313F) Worsening in Pressure Ulcer Status since SOC/ROC:Unstageable - Suspected deep tissue injury|99
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|99
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|99
221|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) g. Advocacy or facilitation of patient's participation in appropriate medical care (includes|999
222|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) a. Patient-specific parameters for notifying physician of changes in vital signs or other cl|999
223|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) b. Diabetic foot care including monitoring for the presence of skin lesions on the lower ext|999
224|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) c. Falls prevention interventions  Plan of Care Synopsis: Does the physician-ordered plan of|999
225|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) d. Depression intervention(s) such as medication, referral for other treatment, or a monitor|999
226|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) e. Intervention(s) to monitor and mitigate pain   Plan of Care Synopsis: Does the physician-|999
227|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) f.  Intervention(s) to prevent pressure ulcers  Plan of Care Synopsis: Does the physician-or|999
228|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician Plan of Care Synopsis: Does the physician-ordered plan of care include the following:|(M2250) g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatmen|999
229|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?|(M1730) Depression Screening: Has the patient been screened for depression, using a standardized dep|999
230|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things:"|(M1730_1)  a.  Ask patient: "Over the last two weeks, how often have you been bothered by little int|999
231|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling down, depressed, or hopeless? "|(M1730_1)  b.  Ask patient: "Over the last two weeks, how often have you been bothered by Feeling do|999
260|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|(M0102) NA - Date of Physician-ordered Start of Care (Resumption of Care):|999
264|(M1005) UK - Inpatient Discharge Date Unknown|(M1005) UK - Inpatient Discharge Date Unknown|999
265|(Box 20) Prognosis:|(Box 20) Prognosis:|999
266|(Box 21) Is the patient DNR:|(Box 21) Is the patient DNR:|999
267|(Box 21) EENT Interventions:|(Box 21) EENT Interventions:|999
268|(Box 21) Neurological Interventions:|(Box 21) Neurological Interventions:|999
269|(Box 21) Vital Signs Interventions|(Box 21) Vital Signs Interventions|999
270|(Box 21) Musculoskeletal Interventions:|(Box 21) Musculoskeletal Interventions:|999
271|(Box 21) Pain Management Interventions:|(Box 21) Pain Management Interventions:|999
272|(Box 21) Integumentary Interventions:|(Box 21) Integumentary Interventions:|999
273|(Box 21) Respiratory Interventions:|(Box 21) Respiratory Interventions:|999
274|(Box 21) Cardiovascular/Hematological Interventions:|(Box 21) Cardiovascular/Hematological Interventions:|999
275|(Box 21) Renal/Genitourinary Interventions:|(Box 21) Renal/Genitourinary Interventions:|999
276|(Box 21) Endocrine Interventions:|(Box 21) Endocrine Interventions:|999
277|(Box 21) Digestive/Gastrointestinal Interventions:|(Box 21) Digestive/Gastrointestinal Interventions:|999
278|(Box 21) Psychiatric/Behavioral Nursing Intervention:|(Box 21) Psychiatric/Behavioral Nursing Intervention:|999
279|(Box 21) Fall Prevention Interventions:|(Box 21) Fall Prevention Interventions:|999
280|(Box 21) Hi-Tech/Special Procedures:|(Box 21) Hi-Tech/Special Procedures:|999
281|(Box 21) Orders for Disciplines and Treatment:|(Box 21) Orders for Disciplines and Treatment:|999
282|(Box 22) Goals/Rehabilitation Potential/Discharge Plans:|(Box 22) Goals/Rehabilitation Potential/Discharge Plans:|999
283|(Box 14) DME and Supplies:|(Box 14) DME and Supplies:|999
284|(Box 18A):Functional Limitations:|(Box 18A):Functional Limitations:|999
285|(Box 18B) Activities Permitted:|(Box 18B) Activities Permitted:|999
286|(Box 19) Mental Status:|(Box 19) Mental Status:|999
287|(Box 15) Safety Measures:|(Box 15) Safety Measures:|999
288|(Box 16) Nutritional Requirements:|(Box 16) Nutritional Requirements:|999
289|(Box 17) Allergies|(Box 17) Allergies|999
290|(Box 21) Terminal Care Interventions|(Box 21) Terminal Care Interventions|999
291|(Box 21) Medical Orders:|(Box 21) Medical Orders:|999
1|(M0014) Branch State (if applicable):|(M0014) Branch State (if applicable):|999
2|(M0016) Branch ID (if applicable):|(M0016) Branch ID (if applicable):|999
3|(M0020) Patient ID Number:|(M0020) Patient ID Number:|999
4|(M0030) Start of Care Date:|(M0030) Start of Care Date:|999
5|(M0032) Resumption of Care Date:|(M0032) Resumption of Care Date:|999
6|(M0040) Patient First Name:|(M0040) Patient First Name:|999
7|(M0040) Patient Last Name|(M0040) Patient Last Name|999
8|(M0040) Patient Middle Initial|(M0040) Patient Middle Initial|999
9|(M0040) Patient Suffix|(M0040) Patient Suffix|999
10|(M0050) Patient State of Residence:|(M0050) Patient State of Residence:|999
11|(M0060) Patient Zip Code:|(M0060) Patient Zip Code:|999
12|(M0063) Medicare Number:  (including suffix)|(M0063) Medicare Number:  (including suffix)|999
13|(M0064) Social Security Number:|(M0064) Social Security Number:|999
14|(M0065) Medicaid Number:|(M0065) Medicaid Number:|999
15|(M0066) Birth Date:|(M0066) Birth Date:|999
16|(M0069) Gender:|(M0069) Gender:|999
17|(M0018) Primary Referring Physician ID:|(M0018) Primary Referring Physician ID:|999
18|(M0080) Discipline of Person Completing Assessment:|(M0080) Discipline of Person Completing Assessment:|999
19|(M0090) Date Assessment Completed:|(M0090) Date Assessment Completed:|999
20|(M0100) This Assessment is Currently Being Completed for the Following Reason:|(M0100) This Assessment is Currently Being Completed for the Following Reason:|999
21|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|(M0140) Race/Ethnicity (as identified by patient):  (Mark all that apply.)|999
22|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|(M0150) Current Payment Sources for Home Care: (Mark all that apply.)|999
23|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? (Mark all that apply.)|(M1000) From which of the following Inpatient Facilities was the patient discharged during the past|999
24|(M1005) Inpatient Discharge Date (most recent):|(M1005) Inpatient Discharge Date (most recent):|999
25|(M1010) a. Inpatient Facility ICD1|(M1010) a. Inpatient Facility ICD1|999
26|(M1010) b. Inpatient Facility ICD2|(M1010) b. Inpatient Facility ICD2|999
27|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a change in medical or treatment regimen (e.g., medication, treatment, or service change due to new or additional diagnosis, etc.) within the last 14 days?|(M0200) Medical or Treatment Regimen Change Within the Past 14 days: Has this patient experienced a|999
28|(M1016) a. Changed Medical Regimen ICD1|(M1016) a. Changed Medical Regimen ICD1|999
29|(M1016) b. Changed Medical Regimen ICD2|(M1016) b. Changed Medical Regimen ICD2|999
30|(M1016) c. Changed Medical Regimen ICD3|(M1016) c. Changed Medical Regimen ICD3|999
31|(M1016) d. Changed Medical Regimen ICD4|(M1016) d. Changed Medical Regimen ICD4|999
32|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen. (Mark all that apply.)|(M1018) Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Day|999
33|(M1020)  Primary Diagnosis:  ICD - Case Mix|(M1020)  Primary Diagnosis:  ICD - Case Mix|999
34|(M1020)  Primary Diagnosis:  Symptom Control Rating|(M1020)  Primary Diagnosis:  Symptom Control Rating|999
35|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the patient is receiving home care and ICD code category (No V-codes)  and rate them using the following severity index. (Choose one value that represents the most severe rating appropriate for each diagnosis.)|(M0230/M0240) Diagnoses and Severity Index: List each medical diagnosis or problem for which the pat|999
36|(M1022) b. Other Diagnosis:  ICD - Case Mix|(M1022) b. Other Diagnosis:  ICD - Case Mix|999
37|(M1022) b. Other Diagnosis:  Symptom Control Rating|(M1022) b. Other Diagnosis:  Symptom Control Rating|999
38|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|(M1022) c. Other Diagnosis:  ICD Code - Case Mix|999
39|(M1022) c. Other Diagnosis:  Symptom Control Rating|(M1022) c. Other Diagnosis:  Symptom Control Rating|999
40|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|(M1022) d. Other Diagnosis:  ICD Code - Case Mix|999
41|(M1022) d. Other Diagnosis:  Symptom Control Rating|(M1022) d. Other Diagnosis:  Symptom Control Rating|999
42|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|(M1022) e. Other Diagnosis:  ICD Code - Case Mix|999
43|(M1022) e. Other Diagnosis:  Symptom Control Rating|(M1022) e. Other Diagnosis:  Symptom Control Rating|999
44|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|(M1022) f. Other Diagnosis:  ICD Code - Case Mix|999
45|(M1022) f. Other Diagnosis:   Symptom Control Rating|(M1022) f. Other Diagnosis:   Symptom Control Rating|999
46|(M0245) a. Payment ICD 1|(M0245) a. Payment ICD 1|999
47|(M0245) b. Payment ICD 2|(M0245) b. Payment ICD 2|999
48|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|(M1030) Therapies the patient receives AT HOME:  (Mark all that apply.)|999
49|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS EPISODE OF ILLNESS.|(M0260) Overall Prognosis:  BEST description of patient's overall prognosis for RECOVERY FROM THIS E|999
50|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|(M0270) Rehabilitative Prognosis:  BEST description of patient's prognosis for FUNCTIONAL STATUS.|999
51|(M0280) Life Expectancy:  (Physician documentation is not required.)|(M0280) Life Expectancy:  (Physician documentation is not required.)|999
52|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: (Mark all that apply.)|(M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome:|999
53|(M0300) Current Residence:|(M0300) Current Residence:|999
54|(M0340) Patient Lives With:  (Mark all that apply.)|(M0340) Patient Lives With:  (Mark all that apply.)|999
55|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|(M0350) Assisting Person(s) Other than Home Care Agency Staff:  (Mark all that apply.)|999
56|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, providing the most frequent assistance, etc. (other than home care agency staff)|(M0360) Primary Caregiver taking LEAD responsibility for providing or managing the patient's care, p|999
57|(M0370) How Often does the patient receive assistance from the primary caregiver?|(M0370) How Often does the patient receive assistance from the primary caregiver?|999
58|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|(M0380) Type of Primary Caregiver Assistance:  (Mark all that apply.)|999
59|(M1200) Vision (with corrective lenses if the patient usually wears them):|(M1200) Vision (with corrective lenses if the patient usually wears them):|999
60|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing aids if the patient usually uses them):|(M0400) Hearing and Ability to Understand Spoken Language in patient's own language (with hearing ai|999
61|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|(M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language):|999
62|(M1242) Frequency of Pain interfering with the patient's activity or movement:|(M1242) Frequency of Pain interfering with the patient's activity or movement:|999
63|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at least daily, affects patient's sleep, appetite, physical or emotional energy,  concentration, personal relationships, emotions, or ability or desire to perform physical activity?|(M0430) Intractable Pain: Is the patient experiencing pain that is NOT EASILY RELIEVED, occurs at le|999
64|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|(M0440) Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES."|999
65|(M0445) Does this patient have a Pressure ulcer?|(M0445) Does this patient have a Pressure ulcer?|999
66|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if none): Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.|(M1308A1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage II (Enter '0' if|999
67|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if none): Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling|(M1308B1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage III (Enter '0' if|999
68|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if none): Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.|(M1308C1) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Stage IV (Enter '0' if|999
69|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to non-removable dressing or device:|(M1308D11) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|999
70|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.|(M1308D21) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|999
71|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:|999
72|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|(M1320) Status of Most Problematic (Observable) Pressure Ulcer:|999
73|(M1330) Does this patient have a Stasis Ulcer?|(M1330) Does this patient have a Stasis Ulcer?|999
74|(M1332) Current Number of (Observable) Stasis Ulcer(s):|(M1332) Current Number of (Observable) Stasis Ulcer(s):|999
75|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a nonremovable dressing?|(M0474) Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence|999
76|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|(M1334) Status of Most Problematic (Observable) Stasis Ulcer:|999
77|(M1340) Does this patient have a Surgical Wound?|(M1340) Does this patient have a Surgical Wound?|999
78|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MORE than one opening, consider each opening as a separate wound.)|(M0484) Current Number of (Observable) Surgical Wounds:  (If a wound is partially closed but has MOR|999
79|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presence of a nonremovable dressing?|(M0486) Does this patient have at least one Surgical Wound that Cannot be Observed due to the presen|999
80|(M1342) Status of Most Problematic (Observable) Surgical Wound:|(M1342) Status of Most Problematic (Observable) Surgical Wound:|999
81|(M1400) When is the patient dyspneic or noticeably Short of Breath?|(M1400) When is the patient dyspneic or noticeably Short of Breath?|999
82|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|(M1410) Respiratory Treatments utilized at home:  (Mark all that apply.)|999
83|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|(M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days?|999
84|(M1610) Urinary Incontinence or Urinary Catheter Presence:|(M1610) Urinary Incontinence or Urinary Catheter Presence:|999
85|(M1615) When does Urinary Incontinence occur?|(M1615) When does Urinary Incontinence occur?|999
86|(M1620) Bowel Incontinence Frequency:|(M1620) Bowel Incontinence Frequency:|999
87|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, OR b) necessitated a change in medical or treatment regimen?|(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (w|999
88|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.|(M1700) Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation|999
89|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|(M1710) When Confused (Reported or Observed Within the Last 14 Days):|999
90|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|(M1720) When Anxious (Reported or Observed Within the Last 14 Days):|999
91|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|(M0590) Depressive Feelings Reported or Observed in Patient:  (Mark all that apply.)|999
92|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK (Reported or Observed):  (Mark all that apply.)|(M1740)  Cognitive, behavioral, and psychiatric symptoms that are demonstrated AT LEAST ONCE A WEEK|999
93|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.|(M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or ot|999
94|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?|(M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psych|999
95|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and hands, hair care, shaving or makeup, teeth or denture care, fingernail care).|(M1800) Grooming:  Current ability to tend safely to personal hygiene needs (i.e., washing face and|999
97|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:|(M1810) Current Ability to Dress UPPER Body safely (with or without dressing aids) including underga|999
99|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:|(M1820) Current ability to Dress LOWER Body safely (with or without dressing aids) including underga|999
101|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and hands and shampooing hair).|(M1830) Bathing:  Current ability to wash entire body safely.  EXCLUDES grooming (washing face and h|999
103|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.|(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely|999
105|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and position self in bed if patient is bedfast.|(M1850) Transferring:  Current ability to move safely from bed to chair or ability to turn and posit|999
107|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces|(M1860) Ambulation/Locomotion:  Current ability to walk safely, once in a standing position, or use|999
109|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refers only to the process of EATING, CHEWING, and SWALLOWING, NOT PREPARING the food to be eaten.|(M1870)  Feeding or Eating:  Current ability to feed self meals and snacks safely.  Note:  This refe|999
111|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely|(M1880) Current ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered|999
121|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing numbers, and EFFECTIVELY use the telephone to communicate.|(M1890) Ability to Use Telephone:  Current ability to answer the phone safely, including dialing num|999
123|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES injectable and IV medications. (NOTE: This refers to ability, not compliance or willingness):|(M2020)  Management of Oral Medications:  PATIENT'S CURRENT ABILITY to prepare and take ALL oral med|999
125|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take ALL prescribed inhalant/mist medications (nebulizers, metered dose devices) reliably and safely, including administration of the correct dosage at the appropriate times/intervals. EXCLUDES all other forms of medication (oral tablets, injectable and IV medications).|(M0790) Current - Management of Inhalant/Mist Medications:  PATIENT'S ABILITY to prepare and take AL|999
127|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals.  EXCLUDES IV medications.|(M2030) Management of Injectable Medications: PATIENT'S CURRENT ABILITY to prepare and take ALL pres|999
129|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or supplies):  (NOTE: This refers to ability, not compliance or willingness.) PATIENT'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0810) Patient Management of Equipment (includes ONLY oxygen, IV/infusion therapy, enteral/parenter|999
182|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?|(M1050) Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from|999
130|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)  (NOTE: This refers to ability, not compliance or willingness.): CAREGIVER'S ABILITY to set up, monitor and change equipment reliably and safely, add appropriate fluids or medication, clean/store/dispose of equipment or supplies using proper technique.|(M0820) Caregiver Management of Equipment (includes ONLY oxygen, IV/infusion equipment, enteral/pare|999
131|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment will define a case mix group indicate a need for therapy (physical, occupational or speech therapy) that meets the threshold for a Medicare high-therapy case mix group?|(M0825) THERAPY NEED Does the care plan of the Medicare payment period for which this assessment wil|999
132|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any of the following services for emergent care (other than home care agency services)?  (Mark all that apply.)|(M0830) Emergent Care:  Since the last time OASIS data were collected, has the patient utilized any|999
133|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark all that apply.)|(M0840) Emergent Care Reason:  For what reason(s) did the patient/family seek emergent care?  (Mark|999
134|(M0855) To which Inpatient Facility has the patient been admitted?|(M0855) To which Inpatient Facility has the patient been admitted?|999
135|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only one  answer.)|(M0870) Discharge Disposition:  Where is the patient after discharge from your agency?  (Choose only|999
136|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistance?  (Mark all that apply.)|(M0880) After discharge, does the patient receive health, personal, or support Services or Assistanc|999
137|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|(M0890) If the patient was admitted to an acute care Hospital, for what Reason was he/she admitted?|999
138|(M0895) Reason for Hospitalization:  (Mark all that apply.)|(M0895) Reason for Hospitalization:  (Mark all that apply.)|999
139|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|(M0900) For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)|999
140|(M0903) Date of Last (Most Recent) Home Visit:|(M0903) Date of Last (Most Recent) Home Visit:|999
141|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home) of the patient:|(M0906) Discharge/Transfer/Death Date:  Enter the date of the discharge, transfer, or death (at home|999
144|Wound Care|Wound Care|999
145|Great presidential Moments|Great presidential Moments|999
147|(M0110) Episode Timing|(M0110) Episode Timing|999
148|(M2200) Therapy Need Number|(M2200) Therapy Need Number|999
149|(M2200) Therapy Need Not Applicable|(M2200) Therapy Need Not Applicable|999
150|(M1024A3) Payment  Diagnosis: Primary, Column 3|(M1024A3) Payment  Diagnosis: Primary, Column 3|999
151|(M1024B3) Payment  Diagnosis First Secondary, Column 3|(M1024B3) Payment  Diagnosis First Secondary, Column 3|999
152|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|(M1024C3) Payment Diagnosis: Second Secondary, Column 3|999
153|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|(M1024D3) Payment Diagnosis:Third Secondary, Column 3|999
154|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|(M1024E3) Payment Diagnosis: Fourth Secondary, Column 3|999
155|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|(M1024F3) Payment Diagnosis: Fifth Secondary, Column 3|999
156|(M1024A4) Payment Diagnosis: Primary, Column 4|(M1024A4) Payment Diagnosis: Primary, Column 4|999
157|(M1024B4) Payment Diagnosis: First Secondary, Column 4|(M1024B4) Payment Diagnosis: First Secondary, Column 4|999
158|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|(M1024C4) Payment Diagnosis: Second Secondary, Column 4|999
159|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|(M1024D4) Payment Diagnosis: Third Secondary, Column 4|999
160|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|(M1024E4) Payment Diagnosis: Fouth Secondary, Column 4|999
161|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|(M1024F4) Payment Diagnosis: Fifth Secondary, Column 4|999
162|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified. month /day/year  (Go to M0110, if date entered)|(M0102) Date of Physician-ordered Start of Care (Resumption of Care): If the physician indicated a s|999
163|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA|(M0104) Date of Referral: Indicate the date that the written or verbal referral for initiation or re|999
164|(M1016) e. Changed Medical Regimen ICD5|(M1016) e. Changed Medical Regimen ICD5|999
166|(M1016) f. Changed Medical Regimen ICD6|(M1016) f. Changed Medical Regimen ICD6|999
168|(M1010) c. Inpatient Facility ICD3|(M1010) c. Inpatient Facility ICD3|999
169|(M1010)d. Inpatient Facility ICD4|(M1010) d. Inpatient Facility ICD4|999
170|(M1010)e. Inpatient Facility ICD5|(M1010) e. Inpatient Facility ICD5|999
171|(M1010)f. Inpatient Facility ICD6|(M1010) f.  Inpatient Facility ICD6|999
172|(M1012) a.  Inpatient Facility Proc 1|(M1012) a. Inpatient Facility Proc 1|999
173|(M1012) b  Inpatient Facility Proc 2|(M1012) b  Inpatient Facility Proc 2|999
174|(M1012) c  Inpatient Facility Proc 3|(M1012) c  Inpatient Facility Proc 3|999
175|(M1012) d  Inpatient Facility Proc 4|(M1012) d  Inpatient Facility Proc 4|999
176|(M1012) NA  Inpatient Facility Proc Not Applicable|(M1012) NA Inpatient Facility Proc Not Applicable|999
177|(M1012) UK  Inpatient Facility Proc Unknown|(M1012) UK Inpatient Facility Proc Unknown|999
178|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)|(M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient|999
179|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|(M1034) Overall Status: Which description best fits the patient+s overall status? (Check one)|999
180|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year+s influenza season (October 1 through March 31) during this episode of care?|(M1040) Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this y|999
181|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine from your agency during this episode of care, state reason:|(M1045) Reason Influenza Vaccine not received: If the patient did not receive the influenza vaccine|999
183|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge), state reason:|(M1055) Reason PPV not received: If patient did not receive the pneumococcal polysaccharide vaccine|999
184|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|(M1210) Ability to hear (with hearing aid or hearing appliance if normally used):|999
185|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used):|(M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if use|999
186|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient+s ability to communicate the severity of pain)?|(M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (app|999
187|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|(M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?|999
188|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|(M1302) Does this patient have a Risk of Developing Pressure Ulcers?|999
189|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designated as "unstageable"?|(M1306) Does this patient have at least one unhealed Pressure Ulcer at Stage II or higher or designa|999
190|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epithelialized) Stage III or IV pressure ulcers, identify the Stage III or IV pressure ulcer with the largest surface dimension (length x width) and record in centimeters. If no Stage III or Stage IV pressure ulcers, go to M1320. Pressure Ulcer Length: Longest length head-to-toe|(M1310) Directions for M1310, M1312 and M1314: If the patient has one or more unhealed (non-epitheli|999
191|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length|(M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the|999
192|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area|(M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest|999
193|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.|(M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a loca|999
194|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?|(M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those|999
195|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?|(M1501) Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did th|999
196|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure at the time of or at any time since the most recent SOC/ROC assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)|(M1511) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited|999
197|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, include cleaning area around stoma, but not managing equipment.|(M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/o|999
198|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?|(M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of mult|999
199|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?|(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically signi|999
200|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?|(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calenda|999
201|(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?|(M2004) Medication Intervention: If there were any clinically significant medication issues since th|999
202|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?|(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the|999
203|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?|(M2110) How often does the patient receive ADL or IADL assistance from any caregiver(s) (other than|999
204|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|(M1016)  NA - Not applicable (no medical or treatment regimen changes within the past 14 days)|999
205|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? (Check one box only).|(M1100)  Patient Living Situation: Which of the following best describes the patient's residential c|999
206|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|(M1307) The Oldest Non-epithelialized Stage II Pressure Ulcer that is present at discharge|999
207|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if none): Suspected deep tissue injury in evolution.|(M1308D31) Current Number of Unhealed (non-epithelialized) Pressure Ulcers Unstageable (Enter '0' if|999
208|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur?|(M2010) Patient/Caregiver High Risk Drug Education: Has the patient/caregiver received instruction o|999
209|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) a. Self-Care (e.g., grooming, dressing, and bathing)  Prior Functioning ADL/IADL: Indicate t|999
210|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) b. Ambulation  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyda|999
211|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) c. Transfer  Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday|999
212|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.|(M1900) d. Household tasks (e.g., light meal preparation, laundry, shopping ) Prior Functioning ADL/|999
213|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) a. Oral Medications Prior Medication Management: Indicate the patient's usual ability with m|999
214|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury.|(M2040) b. Injectable Medications Prior Medication Management: Indicate the patient's usual ability|999
215|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) a. ADL assistance (e.g., transfer/ ambulation, bathing, dressing, toileting, eating/feeding)|999
216|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)  Type|999
217|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) c. Medication administration (e.g., oral, inhaled or injectable) Types and Sources of Assist|999
218|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) d. Medical procedures/ treatments (e.g., changing wound dressing) Types and Sources of Assis|999
219|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutrition, ventilator therapy equipment or supplies) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed|(M2100) e. Management of Equipment (includes oxygen, IV/infusion equipment, enteral/ parenteral nutr|999
220|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed.|(M2100) f. Supervision and safety (e.g., due to cognitive impairment) Types and Sources of Assistanc|999
22|(F2200B) Date patient asked about hospitalization|(F2200B)  Date patient asked about hospitalization|10001
23|(F3000A) Was patient asked spiritual/existent concerns|(F3000A) Was patient asked spiritual/existent concerns|10001
24|(F3000B) Date patient asked spiritual/existent concerns|(F3000B) Date patient asked spiritual/existent concerns|10001
1|(A0100) Facility National Provider Identifier (NPI)|(A0100) NPI_NUM	Facility National Provider Identifier (NPI)|10001
2|(A0100) Facility CMS Certification Number (CCN)|(A0100) Facility CMS Certification Number (CCN)|10001
3|(A0500) Patient First Name|(A0500) Patient First Name|10001
4|(A0500) Patient Initial|(A0500) Patient Initial|10001
5|(A0500) Patient Last Name|(A0500) Patient Last Name|10001
6|(A0500) Patient Suffix|(A0500) Patient Suffix|10001
7|(A0600) Patient SSN|(A0600) Patient SSN|10001
8|(A0600) Patient Medicare/Railroad Insurance Number|(A0600) Patient Medicare Number|10001
9|(A0700) Patient Medicaid Number|(A0700) Patient Medicaid Number|10001
10|(A0800) Gender|(A0800) Gender|10001
11|(A0900) Birthdate|(A0900) Birthday|10001
12|(A1000) Ethnicity|(A1000) Ethnicity|10001
13|(A0205) Site of service at admission|(A0205) Site of service at admission|10001
14|(A0220) Admission Date|(A0220) Admission Date|10001
15|(A0245) Date initial nursing assessment initiated|(A0245) Date initial nursing assessment initiated|10001
16|(A1802) Admitted from|(A1802) Admitted from|10001
17|(F2000A) Was patient Asked About CPR|(F2000A) Was patient Asked About CPR|10001
18|(F2000B) Date patient Asked About CPR|(F2000B) Date Patient Asked About CPR|10001
19|(F2100A) Was patient asked about treatments other than CPR|(F2100A) Was patient asked about treatments other than CPR|10001
20|(F2100B) Date patient asked about treatments other than CPR|(F2100B) Date patient was asked about treatments other than CPR|10001
21|(F2200A) Was patient asked about hospitalization|(F2200A) Was patient asked about hospitalization|10001
25|(I0010) Principal diagnosis|(I0010) Principal diagnosis|10001
26|(J0900A) Was patient screened for pain|(J0900A) Was patient screened for pain|10001
27|(J0900B) Date of first screening for pain|(J0900B) Date of first screening for pain|10001
28|(J0900D) Type of standardized pain screening tool used|(J0900D) Type of standardized pain screening tool used|10001
29|(J0900C) Patient's pain severity was|(J0900C) Patient's pain severity was|10001
30|(J0910A) Was comprehensive pain assessment done|(J0910A) Was comprehensive pain assessment done|10001
31|(J0910B) Date of comprehensive pain assessment|(J0910B)Date of comprehensive pain assessment|10001
32|(J0910C) Pain asmt included:|(J0910C) Pain asmt included:|10001
33|(J2030A) Was patient screened for shortness of breath|(J2030A) Was patient screened for shortness of breath|10001
34|(J2030B) Date of first screening for shortness of breath|(J2030B) Date of first screening for shortness of breath|10001
35|(J2030C) Did screening indicate pt had shortness of breath|(J2030C) Did screening indicate pt had shortness of breath|10001
36|(J2040A) Was treatment for shortness of breath initiated|(J2040A) Was treatment for shortness of breath initiated|10001
37|(J2040B) Date treatment for shortness of breath initiated|(J2040B) Date treatment for shortness of breath initiated|10001
38|(J2040C) Type(s) treat for shortness of breath:|(J2040C) Type(s) treat for shortness of breath:|10001
39|(N0500A) Was scheduled opioid initiated or continued|(N0500A) Was scheduled opioid initiated or continued|10001
40|(N0500B) Date scheduled opioid initiated or continued|(N0500B) Date scheduled opioid initiated or continued|10001
41|(N0510A) Was PRN opioid initiated or continued|(N0510A) Was PRN opioid initiated or continued|10001
42|(N0510B) Date PRN opioid initiated or continued|(N0510B) Date PRN opioid initiated or continued|10001
43|(N0520A) Was bowel regimen initiated or continued|(N0520A) Was bowel regimen initiated or continued|10001
44|(N0520B) Date bowel regimen initiated or continued|(N0520B) Date bowel regimen initiated or continued|10001
45|(Z0500) Date of signature verifying record completion|(Z0500) Date of signature verifying record completion|10001
48|(A0250) Reason for record|(A0250) Reason for record|10001
49|(A0050) Type of record|(A0050) Type of record|10001
1|(A0100) Facility National Provider Identifier (NPI)|(A0100) NPI_NUM Facility National Provider Identifier (NPI)|10002
2|(A0100) Facility CMS Certification Number (CCN)|(A0100) Facility CMS Certification Number (CCN)|10002
3|(A0500) Patient First Name|(A0500) Patient First Name|10002
4|(A0500) Patient Initial|(A0500) Patient Initial|10002
5|(A0500) Patient Last Name|(A0500) Patient Last Name|10002
6|(A0500) Patient Suffix|(A0500) Patient Suffix|10002
7|(A0600) Patient SSN|(A0600) Patient SSN|10002
8|(A0600) Patient Medicare/Railroad Indurane Number|(A0600) Patient Medicare Number|10002
9|(A0700) Patient Medicaid Number|(A0700) Patient Medicaid Number|10002
10|(A0800) Gender|(A0800) Gender|10002
11|(A0900) Birthdate|(A0900) Birthday|10002
14|(A0220) Admission Date|(A0220) Admission Date|10002
45|(Z0500) Date of signature verifying record completion|(Z0500) Date of signature verifying record completion|10002
46|(A0270) Discharge date|(A0270) Discharge date|10002
47|(A2115) Reason for discharge|(A2115) Reason for discharge|10002
48|(A0250) Reason for record|(A0250) Reason for record|10002
1|(A0100) Facility National Provider Identifier (NPI)|(A0100) NPI_NUM	Facility National Provider Identifier (NPI)|10011
2|(A0100) Facility CMS Certification Number (CCN)|(A0100) Facility CMS Certification Number (CCN)|10011
3|(A0500) Patient First Name|(A0500) Patient First Name|10011
4|(A0500) Patient Initial|(A0500) Patient Initial|10011
5|(A0500) Patient Last Name|(A0500) Patient Last Name|10011
6|(A0500) Patient Suffix|(A0500) Patient Suffix|10011
7|(A0600) Patient SSN|(A0600) Patient SSN|10011
8|(A0600) Patient Medicare/Railroad Insurance Number|(A0600) Patient Medicare Number|10011
9|(A0700) Patient Medicaid Number|(A0700) Patient Medicaid Number|10011
10|(A0800) Gender|(A0800) Gender|10011
11|(A0900) Birthdate|(A0900) Birthday|10011
12|(A1000) Ethnicity|(A1000) Ethnicity|10011
13|(A0205) Site of service at admission|(A0205) Site of service at admission|10011
18|(F2000B) Date patient/responsible party Asked About CPR|(F2000B) Date Patient/responsible party Asked About CPR|10011
19|(F2100A) Was patient/responsible party asked about treatments other than CPR|(F2100A) Was patient/responsible party asked about treatments other than CPR|10011
20|(F2100B) Date patient/responsible party asked about treatments other than CPR|(F2100B) Date patient/responsible party was asked about treatments other than CPR|10011
21|(F2200A) Was patient/responsible party asked about hospitalization|(F2200A) Was patient/responsible party asked about hospitalization|10011
22|(F2200B) Date patient/responsible party asked about hospitalization|(F2200B)  Date patient/responsible party asked about hospitalization|10011
23|(F3000A) Was patient/caregiver party asked spiritual/existent concerns|(F3000A) Was patient/caregiver asked spiritual/existent concerns|10011
24|(F3000B) Date patient/caregiver asked spiritual/existent concerns|(F3000B) Date patient/caregiver asked spiritual/existent concerns|10011
25|(I0010) Principal diagnosis|(I0010) Principal diagnosis|10011
26|(J0900A) Was patient screened for pain|(J0900A) Was patient screened for pain|10011
27|(J0900B) Date of first screening for pain|(J0900B) Date of first screening for pain|10011
28|(J0900D) Type of standardized pain screening tool used|(J0900D) Type of standardized pain screening tool used|10011
29|(J0900C) Patient's pain severity was|(J0900C) Patient's pain severity was|10011
30|(J0910A) Was comprehensive pain assessment done|(J0910A) Was comprehensive pain assessment done|10011
31|(J0910B) Date of comprehensive pain assessment|(J0910B)Date of comprehensive pain assessment|10011
32|(J0910C) Pain asmt included:|(J0910C) Pain asmt included:|10011
33|(J2030A) Was patient screened for shortness of breath|(J2030A) Was patient screened for shortness of breath|10011
34|(J2030B) Date of first screening for shortness of breath|(J2030B) Date of first screening for shortness of breath|10011
35|(J2030C) Did screening indicate pt had shortness of breath|(J2030C) Did screening indicate pt had shortness of breath|10011
36|(J2040A) Was treatment for shortness of breath initiated|(J2040A) Was treatment for shortness of breath initiated|10011
37|(J2040B) Date treatment for shortness of breath initiated|(J2040B) Date treatment for shortness of breath initiated|10011
38|(J2040C) Type(s) treat for shortness of breath:|(J2040C) Type(s) treat for shortness of breath:|10011
39|(N0500A) Was scheduled opioid initiated or continued|(N0500A) Was scheduled opioid initiated or continued|10011
40|(N0500B) Date scheduled opioid initiated or continued|(N0500B) Date scheduled opioid initiated or continued|10011
41|(N0510A) Was PRN opioid initiated or continued|(N0510A) Was PRN opioid initiated or continued|10011
42|(N0510B) Date PRN opioid initiated or continued|(N0510B) Date PRN opioid initiated or continued|10011
43|(N0520A) Was bowel regimen initiated or continued|(N0520A) Was bowel regimen initiated or continued|10011
44|(N0520B) Date bowel regimen initiated or continued|(N0520B) Date bowel regimen initiated or continued|10011
45|(Z0500) Date of signature verifying record completion|(Z0500) Date of signature verifying record completion|10011
48|(A0250) Reason for record|(A0250) Reason for record|10011
49|(A0050) Type of record|(A0050) Type of record|10011
50|(A0550) Patient Zip|(A0550) Patient Zip|10011
51|(A1400) Payor Information|(A1400) Payor Information|10011
52|(J0905) Is pain an active problem for the patient?|(J0905) Is pain an active problem for the patient?|10011
14|(A0220) Admission Date|(A0220) Admission Date|10011
15|(A0245) Date initial nursing assessment initiated|(A0245) Date initial nursing assessment initiated|10011
16|(A1802) Admitted from|(A1802) Admitted from|10011
17|(F2000A) Was patient/responsible party Asked About CPR|(F2000A) Was patient/responsible party Asked About CPR|10011
50|(O5000) Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?|(O5000) Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Ca|10012
51|(O5010A1) RN - Num visits - day of death|(O5010A1) RN - Num visits - day of death|10012
52|(O5010A2) RN - Num visits - one day prior to death|(O5010A2) RN - Num visits - one day prior to death|10012
53|(O5010A3) RN - Num visits - two days prior to death|(O5010A3) RN - Num visits - two days prior to death|10012
54|(O5010B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - day of death|(O5010B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - day of death|10012
57|(O5010C1) Medical Social Worker - Num visits - day of death|(O5010C1) Medical Social Worker - Num visits - day of death|10012
58|(O5010C2) Medical Social Worker - Num visits - one day prior to death|(O5010C2) Medical Social Worker - Num visits - one day prior to death|10012
59|(O5010C3) Medical Social Worker - Num visits - two days prior to death|(O5010C3) Medical Social Worker - Num visits - two days prior to death|10012
1|(A0100) Facility National Provider Identifier (NPI)|(A0100) NPI_NUM Facility National Provider Identifier (NPI)|10012
2|(A0100) Facility CMS Certification Number (CCN)|(A0100) Facility CMS Certification Number (CCN)|10012
3|(A0500) Patient First Name|(A0500) Patient First Name|10012
4|(A0500) Patient Initial|(A0500) Patient Initial|10012
5|(A0500) Patient Last Name|(A0500) Patient Last Name|10012
6|(A0500) Patient Suffix|(A0500) Patient Suffix|10012
7|(A0600) Patient SSN|(A0600) Patient SSN|10012
8|(A0600) Patient Medicare/Railroad Indurane Number|(A0600) Patient Medicare Number|10012
9|(A0700) Patient Medicaid Number|(A0700) Patient Medicaid Number|10012
10|(A0800) Gender|(A0800) Gender|10012
11|(A0900) Birthdate|(A0900) Birthday|10012
14|(A0220) Admission Date|(A0220) Admission Date|10012
45|(Z0500) Date of signature verifying record completion|(Z0500) Date of signature verifying record completion|10012
46|(A0270) Discharge date|(A0270) Discharge date|10012
47|(A2115) Reason for discharge|(A2115) Reason for discharge|10012
48|(A0250) Reason for record|(A0250) Reason for record|10012
60|(O5010D1) Chaplain or Spritual Counselor - Num visits - day of death|(O5010D1) Chaplain or Spritual Counselor - Num visits - day of death|10012
61|(O5010D2) Chaplain or Spritual Counselor - Num visits - one day prior to death|(O5010D2) Chaplain or Spritual Counselor - Num visits - one day prior to death|10012
62|(O5010D3) Chaplain or Spritual Counselor - Num visits - two days prior to death|(O5010D3) Chaplain or Spritual Counselor - Num visits - two days prior to death|10012
63|(O5010E1) Licensed Practical Nurse - Num visits - day of death|(O5010E1) Licensed Practical Nurse - Num visits - day of death|10012
64|(O5010E2) Licensed Practical Nurse - Num visits - one day prior to death|(O5010E2) Licensed Practical Nurse - Num visits - one day prior to death|10012
65|(O5010E3) Licensed Practical Nurse - Num visits - two days prior to death|(O5010E3) Licensed Practical Nurse - Num visits - two days prior to death|10012
66|(O5010F1) Aide - Num visits - day of death|(O5010F1) Aide - Num visits - day of death|10012
67|(O5010F2) Aide - Num visits - one day prior to death|(O5010F2) Aide - Num visits - one day prior to death|10012
68|(O5010F3) Aide - Num visits - two days prior to death|(O5010F3) Aide - Num visits - two days prior to death|10012
69|(O5020) Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?|(O5020) Level of care in final 7 days|10012
70|(O5030A1) RN - Num visits - three days prior to death|(O5030A1) RN - Num visits - three days prior to death|10012
71|(O5030A2) RN - Num visits - four days prior to death|(O5030A2) RN - Num visits - four days prior to death|10012
72|(O5030A3) RN - Num visits - five days prior to death|(O5030A3) RN - Num visits - five days prior to death|10012
73|(O5030A4) RN - Num visits - six days prior to death|(O5030A4) RN - Num visits - six days prior to death|10012
78|(O5030C1) Medical Social Worker - Num visits - three days prior to death|(O5030C1) Medical Social Worker - Num visits - three days prior to death|10012
79|(O5030C2) Medical Social Worker - Num visits - four days prior to death|(O5030C2) Medical Social Worker - Num visits - four days prior to death|10012
80|(O5030C3) Medical Social Worker - Num visits - five days prior to death|(O5030C3) Medical Social Worker - Num visits - five days prior to death|10012
81|(O5030C4) Medical Social Worker - Num visits - six days prior to death|(O5030C4) Medical Social Worker - Num visits - six days prior to death|10012
82|(O5030D1) Chaplain or Spritual Counselor - Num visits - three days prior to death|(O5030D1) Chaplain or Spritual Counselor - Num visits - three days prior to death|10012
83|(O5030D2) Chaplain or Spritual Counselor - Num visits - four days prior to death|(O5030D2) Chaplain or Spritual Counselor - Num visits - four days prior to death|10012
84|(O5030D3) Chaplain or Spritual Counselor - Num visits - five days prior to death|(O5030D3) Chaplain or Spritual Counselor - Num visits - five days prior to death|10012
85|(O5030D4) Chaplain or Spritual Counselor - Num visits - six days prior to death|(O5030D4) Chaplain or Spritual Counselor - Num visits - six days prior to death|10012
86|(O5030E1) Licensed Practical Nurse - Num visits - three days prior to death|(O5030E1) Licensed Practical Nurse - Num visits - three days prior to death|10012
87|(O5030E2) Licensed Practical Nurse - Num visits - four days prior to death|(O5030E2) Licensed Practical Nurse - Num visits - four days prior to death|10012
88|(O5030E3) Licensed Practical Nurse - Num visits - five days prior to death|(O5030E3) Licensed Practical Nurse - Num visits - five days prior to death|10012
89|(O5030E4) Licensed Practical Nurse - Num visits - six days prior to death|(O5030E4) Licensed Practical Nurse - Num visits - six days prior to death|10012
90|(O5030F1) Aide - Num visits - three days prior to death|(O5030F1) Aide - Num visits - three days prior to death|10012
91|(O5030F2) Aide - Num visits - four days prior to death|(O5030F2) Aide - Num visits - four days prior to death|10012
92|(O5030F3) Aide - Num visits - five days prior to death|(O5030F3) Aide - Num visits - five days prior to death|10012
93|(O5030F4) Aide - Num visits - six days prior to death|(O5030F4) Aide - Num visits - six days prior to death|10012
55|(O5010B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - one day prior to death|(O5010B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - one day|10012
56|(O5010B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - two days prior to death|(O5010B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - two days|10012
74|(O5030B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - three days prior to death|(O5030B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - three days|10012
75|(O5030B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - four days prior to death|(O5030B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - four days|10012
76|(O5030B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - five days prior to death|(O5030B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - five days|10012
77|(O5030B4) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - six days prior to death|(O5030B4) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - six days|10012
1|(A0100) Facility National Provider Identifier (NPI)|(A0100) NPI_NUM	Facility National Provider Identifier (NPI)|10021
2|(A0100) Facility CMS Certification Number (CCN)|(A0100) Facility CMS Certification Number (CCN)|10021
3|(A0500) Patient First Name|(A0500) Patient First Name|10021
4|(A0500) Patient Initial|(A0500) Patient Initial|10021
5|(A0500) Patient Last Name|(A0500) Patient Last Name|10021
6|(A0500) Patient Suffix|(A0500) Patient Suffix|10021
7|(A0600) Patient SSN|(A0600) Patient SSN|10021
8|(A0600) Patient Medicare/Railroad Insurance Number|(A0600) Patient Medicare Number|10021
9|(A0700) Patient Medicaid Number|(A0700) Patient Medicaid Number|10021
10|(A0800) Gender|(A0800) Gender|10021
11|(A0900) Birthdate|(A0900) Birthday|10021
12|(A1000) Ethnicity|(A1000) Ethnicity|10021
13|(A0205) Site of service at admission|(A0205) Site of service at admission|10021
14|(A0220) Admission Date|(A0220) Admission Date|10021
15|(A0245) Date initial nursing assessment initiated|(A0245) Date initial nursing assessment initiated|10021
16|(A1802) Admitted from|(A1802) Admitted from|10021
17|(F2000A) Was patient/responsible party Asked About CPR|(F2000A) Was patient/responsible party Asked About CPR|10021
18|(F2000B) Date patient/responsible party Asked About CPR|(F2000B) Date Patient/responsible party Asked About CPR|10021
19|(F2100A) Was patient/responsible party asked about treatments other than CPR|(F2100A) Was patient/responsible party asked about treatments other than CPR|10021
20|(F2100B) Date patient/responsible party asked about treatments other than CPR|(F2100B) Date patient/responsible party was asked about treatments other than CPR|10021
21|(F2200A) Was patient/responsible party asked about hospitalization|(F2200A) Was patient/responsible party asked about hospitalization|10021
22|(F2200B) Date patient/responsible party asked about hospitalization|(F2200B)  Date patient/responsible party asked about hospitalization|10021
23|(F3000A) Was patient/caregiver party asked spiritual/existent concerns|(F3000A) Was patient/caregiver asked spiritual/existent concerns|10021
24|(F3000B) Date patient/caregiver asked spiritual/existent concerns|(F3000B) Date patient/caregiver asked spiritual/existent concerns|10021
25|(I0010) Principal diagnosis|(I0010) Principal diagnosis|10021
26|(J0900A) Was patient screened for pain|(J0900A) Was patient screened for pain|10021
27|(J0900B) Date of first screening for pain|(J0900B) Date of first screening for pain|10021
28|(J0900D) Type of standardized pain screening tool used|(J0900D) Type of standardized pain screening tool used|10021
29|(J0900C) Patient's pain severity was|(J0900C) Patient's pain severity was|10021
30|(J0910A) Was comprehensive pain assessment done|(J0910A) Was comprehensive pain assessment done|10021
31|(J0910B) Date of comprehensive pain assessment|(J0910B)Date of comprehensive pain assessment|10021
32|(J0910C) Pain asmt included:|(J0910C) Pain asmt included:|10021
33|(J2030A) Was patient screened for shortness of breath|(J2030A) Was patient screened for shortness of breath|10021
34|(J2030B) Date of first screening for shortness of breath|(J2030B) Date of first screening for shortness of breath|10021
35|(J2030C) Did screening indicate pt had shortness of breath|(J2030C) Did screening indicate pt had shortness of breath|10021
36|(J2040A) Was treatment for shortness of breath initiated|(J2040A) Was treatment for shortness of breath initiated|10021
37|(J2040B) Date treatment for shortness of breath initiated|(J2040B) Date treatment for shortness of breath initiated|10021
38|(J2040C) Type(s) treat for shortness of breath:|(J2040C) Type(s) treat for shortness of breath:|10021
39|(N0500A) Was scheduled opioid initiated or continued|(N0500A) Was scheduled opioid initiated or continued|10021
40|(N0500B) Date scheduled opioid initiated or continued|(N0500B) Date scheduled opioid initiated or continued|10021
41|(N0510A) Was PRN opioid initiated or continued|(N0510A) Was PRN opioid initiated or continued|10021
42|(N0510B) Date PRN opioid initiated or continued|(N0510B) Date PRN opioid initiated or continued|10021
43|(N0520A) Was bowel regimen initiated or continued|(N0520A) Was bowel regimen initiated or continued|10021
44|(N0520B) Date bowel regimen initiated or continued|(N0520B) Date bowel regimen initiated or continued|10021
45|(Z0500) Date of signature verifying record completion|(Z0500) Date of signature verifying record completion|10021
48|(A0250) Reason for record|(A0250) Reason for record|10021
49|(A0050) Type of record|(A0050) Type of record|10021
50|(A0550) Patient Zip|(A0550) Patient Zip|10021
51|(A1400) Payor Information|(A1400) Payor Information|10021
52|(J0905) Is pain an active problem for the patient?|(J0905) Is pain an active problem for the patient?|10021
57|(O5010C1) Medical Social Worker - Num visits - day of death|(O5010C1) Medical Social Worker - Num visits - day of death|10022
58|(O5010C2) Medical Social Worker - Num visits - one day prior to death|(O5010C2) Medical Social Worker - Num visits - one day prior to death|10022
59|(O5010C3) Medical Social Worker - Num visits - two days prior to death|(O5010C3) Medical Social Worker - Num visits - two days prior to death|10022
60|(O5010D1) Chaplain or Spritual Counselor - Num visits - day of death|(O5010D1) Chaplain or Spritual Counselor - Num visits - day of death|10022
61|(O5010D2) Chaplain or Spritual Counselor - Num visits - one day prior to death|(O5010D2) Chaplain or Spritual Counselor - Num visits - one day prior to death|10022
62|(O5010D3) Chaplain or Spritual Counselor - Num visits - two days prior to death|(O5010D3) Chaplain or Spritual Counselor - Num visits - two days prior to death|10022
63|(O5010E1) Licensed Practical Nurse - Num visits - day of death|(O5010E1) Licensed Practical Nurse - Num visits - day of death|10022
64|(O5010E2) Licensed Practical Nurse - Num visits - one day prior to death|(O5010E2) Licensed Practical Nurse - Num visits - one day prior to death|10022
65|(O5010E3) Licensed Practical Nurse - Num visits - two days prior to death|(O5010E3) Licensed Practical Nurse - Num visits - two days prior to death|10022
66|(O5010F1) Aide - Num visits - day of death|(O5010F1) Aide - Num visits - day of death|10022
67|(O5010F2) Aide - Num visits - one day prior to death|(O5010F2) Aide - Num visits - one day prior to death|10022
68|(O5010F3) Aide - Num visits - two days prior to death|(O5010F3) Aide - Num visits - two days prior to death|10022
1|(A0100) Facility National Provider Identifier (NPI)|(A0100) NPI_NUM Facility National Provider Identifier (NPI)|10022
2|(A0100) Facility CMS Certification Number (CCN)|(A0100) Facility CMS Certification Number (CCN)|10022
3|(A0500) Patient First Name|(A0500) Patient First Name|10022
4|(A0500) Patient Initial|(A0500) Patient Initial|10022
5|(A0500) Patient Last Name|(A0500) Patient Last Name|10022
6|(A0500) Patient Suffix|(A0500) Patient Suffix|10022
7|(A0600) Patient SSN|(A0600) Patient SSN|10022
8|(A0600) Patient Medicare/Railroad Indurane Number|(A0600) Patient Medicare Number|10022
9|(A0700) Patient Medicaid Number|(A0700) Patient Medicaid Number|10022
10|(A0800) Gender|(A0800) Gender|10022
11|(A0900) Birthdate|(A0900) Birthday|10022
14|(A0220) Admission Date|(A0220) Admission Date|10022
45|(Z0500) Date of signature verifying record completion|(Z0500) Date of signature verifying record completion|10022
46|(A0270) Discharge date|(A0270) Discharge date|10022
47|(A2115) Reason for discharge|(A2115) Reason for discharge|10022
48|(A0250) Reason for record|(A0250) Reason for record|10022
50|(O5000) Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 3 days of life?|(O5000) Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Ca|10022
51|(O5010A1) RN - Num visits - day of death|(O5010A1) RN - Num visits - day of death|10022
52|(O5010A2) RN - Num visits - one day prior to death|(O5010A2) RN - Num visits - one day prior to death|10022
53|(O5010A3) RN - Num visits - two days prior to death|(O5010A3) RN - Num visits - two days prior to death|10022
54|(O5010B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - day of death|(O5010B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - day of death|10022
55|(O5010B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - one day prior to death|(O5010B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - one day|10022
56|(O5010B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - two days prior to death|(O5010B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - two days|10022
69|(O5020) Did the patient receive Continuous Home Care, General Inpatient Care, or Respite Care during any of the final 7 days of life?|(O5020) Level of care in final 7 days|10022
70|(O5030A1) RN - Num visits - three days prior to death|(O5030A1) RN - Num visits - three days prior to death|10022
71|(O5030A2) RN - Num visits - four days prior to death|(O5030A2) RN - Num visits - four days prior to death|10022
72|(O5030A3) RN - Num visits - five days prior to death|(O5030A3) RN - Num visits - five days prior to death|10022
73|(O5030A4) RN - Num visits - six days prior to death|(O5030A4) RN - Num visits - six days prior to death|10022
74|(O5030B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - three days prior to death|(O5030B1) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - three days|10022
75|(O5030B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - four days prior to death|(O5030B2) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - four days|10022
76|(O5030B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - five days prior to death|(O5030B3) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - five days|10022
77|(O5030B4) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - six days prior to death|(O5030B4) Physician (or Nurse Practitioner or Physician Assistant) - Num visits - six days|10022
78|(O5030C1) Medical Social Worker - Num visits - three days prior to death|(O5030C1) Medical Social Worker - Num visits - three days prior to death|10022
79|(O5030C2) Medical Social Worker - Num visits - four days prior to death|(O5030C2) Medical Social Worker - Num visits - four days prior to death|10022
80|(O5030C3) Medical Social Worker - Num visits - five days prior to death|(O5030C3) Medical Social Worker - Num visits - five days prior to death|10022
81|(O5030C4) Medical Social Worker - Num visits - six days prior to death|(O5030C4) Medical Social Worker - Num visits - six days prior to death|10022
82|(O5030D1) Chaplain or Spritual Counselor - Num visits - three days prior to death|(O5030D1) Chaplain or Spritual Counselor - Num visits - three days prior to death|10022
83|(O5030D2) Chaplain or Spritual Counselor - Num visits - four days prior to death|(O5030D2) Chaplain or Spritual Counselor - Num visits - four days prior to death|10022
84|(O5030D3) Chaplain or Spritual Counselor - Num visits - five days prior to death|(O5030D3) Chaplain or Spritual Counselor - Num visits - five days prior to death|10022
85|(O5030D4) Chaplain or Spritual Counselor - Num visits - six days prior to death|(O5030D4) Chaplain or Spritual Counselor - Num visits - six days prior to death|10022
86|(O5030E1) Licensed Practical Nurse - Num visits - three days prior to death|(O5030E1) Licensed Practical Nurse - Num visits - three days prior to death|10022
87|(O5030E2) Licensed Practical Nurse - Num visits - four days prior to death|(O5030E2) Licensed Practical Nurse - Num visits - four days prior to death|10022
88|(O5030E3) Licensed Practical Nurse - Num visits - five days prior to death|(O5030E3) Licensed Practical Nurse - Num visits - five days prior to death|10022
89|(O5030E4) Licensed Practical Nurse - Num visits - six days prior to death|(O5030E4) Licensed Practical Nurse - Num visits - six days prior to death|10022
90|(O5030F1) Aide - Num visits - three days prior to death|(O5030F1) Aide - Num visits - three days prior to death|10022
91|(O5030F2) Aide - Num visits - four days prior to death|(O5030F2) Aide - Num visits - four days prior to death|10022
92|(O5030F3) Aide - Num visits - five days prior to death|(O5030F3) Aide - Num visits - five days prior to death|10022
93|(O5030F4) Aide - Num visits - six days prior to death|(O5030F4) Aide - Num visits - six days prior to death|10022
267|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying flat on the bed.|(GG0170B4) Sit to lying (Follow-Up Perf): The ability to move from sitting on side of bed to lying f|75268
