86244-1  Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up: -: Pt: ^Patient: -: CMS Assessment  

PANEL HIERARCHY

  LOINC#   LOINC Name R/O/C  Cardinality  Ex. UCUM Units 
  86244-1   Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up: -: Pt: ^Patient: -: CMS Assessment    
       86245-8   CLINICAL RECORD ITEMS    
            46500-5   Discipline of Person Completing Assessment    
            46501-3   Date Assessment Completed   {mm/dd/yyyy} 
            57200-8   This Assessment is Currently Being Completed for the Following Reason    
            57203-2   Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?    
       86246-6   PATIENT HISTORY AND DIAGNOSES    
            46504-7   Inpatient Facility Diagnosis: ICD-10-CM Code 1..6   
            85911-6   Diagnoses, Symptom Control, and Optional Diagnoses    
                 85912-4   Primary Diagnosis    
                      86255-7   Primary Diagnosis: ICD-10-code    
                      85920-7   Primary Diagnosis Symptom Control Rating    
                      85914-0   Optional Diagnosis: ICD-10-CM    
                      86254-0   Optional Diagnosis: ICD-10-CM - multiple coding    
                 85913-2   Other Diagnoses 0..5   
                      81885-6   Other Diagnoses: ICD-10-CM    
                      85920-7   Other Diagnoses Symptom Control Rating    
                      85914-0   Optional Diagnosis: ICD-10-CM    
                      86254-0   Optional Diagnosis: ICD-10-CM - multiple coding    
            46466-9   Therapies the patient receives at home 1..3   
       86247-4   SENSORY STATUS    
            57215-6   Vision (with corrective lenses if the patient usually wears them)    
            57220-6   Frequency of pain interfering with patient's activity or movement    
       86248-2   INTEGUMENTARY STATUS    
            85918-1   Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as Unstageable?    
            86270-6   Current Number of Unhealed Pressure Ulcers at Each Stage    
                 55124-2   Number of Stage 2 pressure ulcers   {#} 
                 54886-7   Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC   {#} 
                 55125-9   Number of Stage 3 pressure ulcers   {#} 
                 54887-5   Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC   {#} 
                 55126-7   Number of Stage 4 pressure ulcers   {#} 
                 54890-9   Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC   {#} 
                 54893-3   Number of unstageable pressure ulcers due to non-removable dressing/device   {#} 
                 54894-1   Number of these unstageable pressure ulcers that were present at most recent SOC/ROC   {#} 
                 54946-9   Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar   {#} 
                 54947-7   Number of these unstageable pressure ulcers that were present at most recent SOC/ROC   {#} 
                 54950-1   Number of unstageable pressure ulcers with suspected deep tissue injury in evolution   {#} 
                 54951-9   Number of these unstageable pressure ulcers that were present at most recent SOC/ROC   {#} 
            46536-9   Current Number of Stage 1 Pressure Ulcers   {#} 
            57231-3   Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable    
            57232-1   Does this patient have a Stasis Ulcer?    
            57233-9   Current Number of Stasis Ulcer(s) that are Observable   {#} 
            57234-7   Status of Most Problematic Stasis Ulcer that is Observable    
            57235-4   Does this patient have a Surgical Wound?    
            57236-2   Status of Most Problematic Surgical Wound that is Observable    
       86249-0   RESPIRATORY STATUS    
            57237-0   When is the patient dyspneic or noticeably Short of Breath?    
       86250-8   ELIMINATION STATUS    
            46553-4   Urinary Incontinence or Urinary Catheter Presence    
            46587-2   Bowel Incontinence Frequency    
            86471-0   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?    
       86251-6   ADL & IADLs    
            46597-1   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.    
            46599-7   Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.    
            57243-8   Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).    
            57244-6   Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.    
            57246-1   Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.    
            57247-9   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.    
       86252-4   MEDICATIONS    
            57284-2   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.    
       86253-2   THERAPY NEED AND PLAN OF CARE    
            57268-5   Therapy need: Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined).   {#} 
 

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up  Pt  ^Patient  CMS Assessment
  Long Common Name:  Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  This information is collected at Recertification and Other Follow-up. This panel should be used for CMS OASIS-C2 Follow-up - recertification or other follow-up assessments performed between January 1, 2017 and December 31, 2018.
 
 

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Panel
  First Released in Version: 2.63
  Last Updated in Version: 2.66
  Order vs. Obs.: Order
  Status: Active

PARTS

Part Type    Part No.  Part Name   
Component   LP249860-0  Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21049-9  Other 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Pan Point in time
  Form version Panel Random
  LTPAC PANEL.SURVEY.CMS Survey
  Othr Panl  
  Outcome and assessment information set Pnl  

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Long Common Name: Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  Fully Specified Name: Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 16
  ID: 91785
  # of Panel Elements: 62
  Status (Raw): ACTIVE



Selected information about each LOINC that is part of this panel



86245-8   Clinical Record Items - follow-up [CMS Assessment]Clinical Record Items - follow-up [CMS Assessment]Clinical record items - follow-up: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Clinical record items - follow-up  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  CLINICAL RECORD ITEMS
  Long Common Name:  Clinical Record Items - follow-up [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250642-8  Clinical record items - follow-up 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Point in time
  Pan Panl Random
  Panel Pnl Survey

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Long Common Name: Clinical Record Items - follow-up [CMS Assessment]
  Fully Specified Name: Clinical record items - follow-up: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 5
  ID: 91786
  Status (Raw): ACTIVE


46500-5   Discipline of Person Completing Assessment Provider [CMS Assessment]Discipline of Person Completing Assessment Provider [CMS Assessment]Discipline of person completing assessment: Type: Pt: Provider: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Discipline of person completing assessment  Type  Pt  Provider  Nom  CMS Assessment
  Override Display Name for Form:  Discipline of Person Completing Assessment
  Long Common Name:  Discipline of Person Completing Assessment Provider [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies the discipline of the clinician completing the comprehensive assessment at the specified time points or the clinician reporting the transfer to an inpatient facility, death at home, or discharge (no further visits after start of care).
 
 

OBSERVATION ID IN FORM
M0080

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL245-2)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  1       RN       1       LA6367-2  
  2       PT       2       LA6353-2  
  3       SLP/ST       3       LA6378-9  
  4       OT       4       LA6309-4  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  46462-8 Outcome and assessment information set (OASIS) form - version B1
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
  86261-5 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88370-2 Outcome and assessment information set (OASIS) form - version D - Discharged from agency - death at home [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74749-0  Discipline of person completing assessment 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
System   LP7504-6  Provider 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP91379-5  Person 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Typ
  Nominal Random  
  Persons Survey  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0080     D 
   CMS OASIS   M0080     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Attachment Units Required: N
  Long Common Name: Discipline of Person Completing Assessment Provider [CMS Assessment]
  Fully Specified Name: Discipline of person completing assessment: Type: Pt: Provider: Nom: CMS Assessment
     
  Component Word Count: 5
  ID: 38414
  Status (Raw): ACTIVE


46501-3   Date assessment information completed [CMS Assessment]Date assessment information completed [CMS Assessment]Date assessment information completed: Date: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Date assessment information completed  Date  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Date Assessment Completed
  Long Common Name:  Date assessment information completed [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  The actual date the assessment is completed, except if agency policy allows assessments to be performed over more than one visit date, in which case the last date (when the assessment is finished) is the appropriate date to record.
 
 

OBSERVATION ID IN FORM
M0090

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  46462-8 Outcome and assessment information set (OASIS) form - version B1
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  62812-3 PhenX domain - Physical activity and physical fitness
  62863-6 PhenX domain - Infectious diseases and immunity
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
  86261-5 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88370-2 Outcome and assessment information set (OASIS) form - version D - Discharged from agency - death at home [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74694-8  Date assessment information completed 
Property   LP182451-7  Date 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Quan Random
  Point in time Quant Survey
  QNT Quantitative  

EXAMPLE UNITS
  Unit  Source Type
  {mm/dd/yyyy}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {mm/dd/yyyy} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0090     C2 
   CMS OASIS   M0090     D 
   https://www.phenxtoolkit.org   PX150801290101   PX150801_Diary_Day1_Date_Month   
   https://www.phenxtoolkit.org   PX150801290102   PX150801_Diary_Day1_Date_Day   
   https://www.phenxtoolkit.org   PX150801290103   PX150801_Diary_Day1_Date_Year   
   https://www.phenxtoolkit.org   PX150801300101   PX150801_Diary_Day2_Date_Month   
   https://www.phenxtoolkit.org   PX150801300102   PX150801_Diary_Day2_Date_Day   
   https://www.phenxtoolkit.org   PX150801300103   PX150801_Diary_Day2_Date_Year   
   https://www.phenxtoolkit.org   PX150801310101   PX150801_Diary_Day3_Date_Month   
   https://www.phenxtoolkit.org   PX150801310102   PX150801_Diary_Day3_Date_Day   
   https://www.phenxtoolkit.org   PX150801310103   PX150801_Diary_Day3_Date_Year   
   https://www.phenxtoolkit.org   PX150801320101   PX150801_Diary_Day4_Date_Month   
   https://www.phenxtoolkit.org   PX150801320102   PX150801_Diary_Day4_Date_Day   
   https://www.phenxtoolkit.org   PX150801320103   PX150801_Diary_Day4_Date_Year   
   https://www.phenxtoolkit.org   PX150801330101   PX150801_Diary_Day5_Date_Month   
   https://www.phenxtoolkit.org   PX150801330102   PX150801_Diary_Day5_Date_Day   
   https://www.phenxtoolkit.org   PX150801330103   PX150801_Diary_Day5_Date_Year   
   https://www.phenxtoolkit.org   PX150801340101   PX150801_Diary_Day6_Date_Month   
   https://www.phenxtoolkit.org   PX150801340102   PX150801_Diary_Day6_Date_Day   
   https://www.phenxtoolkit.org   PX150801340103   PX150801_Diary_Day6_Date_Year   
   https://www.phenxtoolkit.org   PX150801350101   PX150801_Diary_Day7_Date_Month   
   https://www.phenxtoolkit.org   PX150801350102   PX150801_Diary_Day7_Date_Day   
   https://www.phenxtoolkit.org   PX150801350103   PX150801_Diary_Day7_Date_Year   
   https://www.phenxtoolkit.org   PX161201030100   PX161201_Date_Month   
   https://www.phenxtoolkit.org   PX161201030200   PX161201_Date_Day   
   https://www.phenxtoolkit.org   PX161201030300   PX161201_Date_Year   
   https://www.phenxtoolkit.org   PX161201040000   PX161201_Country_Of_Birth   

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Attachment Units Required: N
  Long Common Name: Date assessment information completed [CMS Assessment]
  Fully Specified Name: Date assessment information completed: Date: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 4
  ID: 38415
  Status (Raw): ACTIVE


57200-8   Reason for assessment [CMS Assessment]Reason for assessment [CMS Assessment]Reason for assessment: Find: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Reason for assessment  Find  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  This Assessment is Currently Being Completed for the Following Reason
  Long Common Name:  Reason for assessment [CMS Assessment]

OBSERVATION ID IN FORM
M0100

SKIP LOGIC
If 4, go to M0110. If 5, go to M0110.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL773-3)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Start of care - further visits planned       1       LA6390-4  
  2       Resumption of care (after inpatient stay)       3       LA6366-4  
  3       Recertification (follow-up) reassessment       4       LA6355-7  
  4       Other follow-up       5       LA6312-8  
  5       Transferred to an inpatient facility - patient not discharged from agency       6       LA6402-7  
  6       Transferred to an inpatient facility - patient discharged from agency       7       LA6401-9  
  7       Death at home       8       LA6179-1  
  8       Discharge from agency       9       LA6184-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86259-9 Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
  86261-5 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88367-8 Outcome and assessment information set (OASIS) form - version D - Transfer to inpatient facility - patient discharged or not discharged [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88370-2 Outcome and assessment information set (OASIS) form - version D - Discharged from agency - death at home [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75490-0  Reason for assessment 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal Survey
  Finding Point in time  
  Findings Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0100     D 
   CMS OASIS   M0100     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Attachment Units Required: N
  Long Common Name: Reason for assessment [CMS Assessment]
  Fully Specified Name: Reason for assessment: Find: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 3
  ID: 51830
  Status (Raw): ACTIVE


57203-2   Episode Timing [CMS Assessment]Episode Timing [CMS Assessment]Episode Timing: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Episode Timing  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?
  Long Common Name:  Episode Timing [CMS Assessment]

OBSERVATION ID IN FORM
M0110

FORM CONTEXT
Is the Medicare home health payment episode for which this assessment will define a case mix group an “early” episode or a “later” episode in the patient’s current sequence of adjacent Medicare home health payment episodes?

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms.

NORMATIVE ANSWER LIST    (LL774-1)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Early       1       LA12111-3  
  2       Later       2       LA12112-1  
  3       Unknown
http://snomed.info/sct ©: 261665006 Unknown (qualifier value)    
  UK       LA4489-6  
  4       Not Applicable: No Medicare case mix group to be defined by this assessment.       NA       LA12114-7  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57193-5 Outcome and assessment information set (OASIS) form - version C - Transfer to facility
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  57459-0 Outcome and assessment information set (OASIS) form - version C - Death at home
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP97189-2  Episode Timing 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M0110     D 
   CMS OASIS   M0110     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Attachment Units Required: N
  Long Common Name: Episode Timing [CMS Assessment]
  Fully Specified Name: Episode Timing: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 51833
  Status (Raw): ACTIVE


86246-6   OASIS C2 - Patient history and diagnoses - follow-up [CMS Assessment]OASIS C2 - Patient history and diagnoses - follow-up [CMS Assessment]OASIS C2 - Patient history and diagnoses - follow-up: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS C2 - Patient history and diagnoses - follow-up  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  PATIENT HISTORY AND DIAGNOSES
  Long Common Name:  OASIS C2 - Patient history and diagnoses - follow-up [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250636-0  OASIS C2 - Patient history and diagnoses - follow-up 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP91302-7  History 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Random
  Hx Panl Survey
  Outcome and assessment information set Patient Hx  
  Pan Pnl  
  Panel Point in time  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Long Common Name: OASIS C2 - Patient history and diagnoses - follow-up [CMS Assessment]
  Fully Specified Name: OASIS C2 - Patient history and diagnoses - follow-up: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 8
  ID: 91787
  Status (Raw): ACTIVE


46504-7   Inpatient stay within last 14 days - ICD code [CMS Assessment]Inpatient stay within last 14 days - ICD code [CMS Assessment]Inpatient stay within last 14D - ICD code: Prid: 14D: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Inpatient stay within last 14D - ICD code  Prid  14D  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Inpatient Facility Diagnosis: ICD-10-CM Code
  Long Common Name:  Inpatient stay within last 14 days - ICD code [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies diagnosis(es) for which patient was receiving treatment in an inpatient facility within the past 14 days. (Past 14 days encompasses the two-week period immediately preceding the start/resumption of care.)
 
 

OBSERVATION ID IN FORM
M1011a-M1011f

ANSWER CARDINALITY
1..6

FORM CODING INSTRUCTIONS
List each Inpatient Diagnosis and ICD-10-CM code at the level of highest specificity for only those conditions actively treated during an inpatient stay having a discharge date within the last 14 days (no V, W, X, Y, or Z codes or surgical codes).

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

EXAMPLE ANSWER LIST    (LL343-5)  
 
Externally Defined: Y
Source: National Center for Health Statistics

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  46462-8 Outcome and assessment information set (OASIS) form - version B1 LL343-5 NORMATIVE 1
  57039-0 Outcome and assessment information set (OASIS) form - version C LL343-5 NORMATIVE 1
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL343-5 NORMATIVE 1
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL343-5 NORMATIVE 1
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP74981-9  Inpatient stay within last 14D - ICD code   [Inpatient stay within last 14 days - ICD code] 
Property   LP6850-4  Prid   [Presence or Identity] 
Time   LP203020-5  14D   [14 days] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP200101-6  Last 
Fragments for synonyms   LP57597-4  ICD 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal  
  Identity or presence Past  
  International Classification of Diseases Survey  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1011     C2 
   CMS OASIS   M1011a     C2 
   CMS OASIS   M1011b     C2 
   CMS OASIS   M1011c     C2 
   CMS OASIS   M1011d     C2 
   CMS OASIS   M1011e     C2 
   CMS OASIS   M1011f     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Attachment Units Required: N
  Long Common Name: Inpatient stay within last 14 days - ICD code [CMS Assessment]
  Fully Specified Name: Inpatient stay within last 14D - ICD code: Prid: 14D: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 7
  ID: 38418
  Status (Raw): ACTIVE


85911-6   Diagnoses, symptom control, and optional diagnoses [CMS Assessment]Diagnoses, symptom control, and optional diagnoses [CMS Assessment]Diagnoses, symptom control, and optional diagnoses: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Diagnoses, symptom control, and optional diagnoses  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  Diagnoses, Symptom Control, and Optional Diagnoses
  Long Common Name:  Diagnoses, symptom control, and optional diagnoses [CMS Assessment]

OBSERVATION ID IN FORM
M1021, M1023, M1025

FORM CODING INSTRUCTIONS
List each diagnosis for which the patient is receiving home care in Column 1, and enter its ICD-10-CM code at the level of highest specificity in Column 2 (diagnosis codes only - no surgical or procedure codes allowed). Diagnoses are listed in the order that best reflects the seriousness of each condition and supports the disciplines and services provided. Rate the degree of symptom control for each condition in Column 2. ICD-10-CM sequencing requirements must be followed if multiple coding is indicated for any diagnoses. If a Z-code is reported in Column 2 in place of a diagnosis that is no longer active (a resolved condition), then optional item M1025 (Optional Diagnoses - Columns 3 and 4) may be completed. Diagnoses reported in M1025 will not impact payment.

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249808-9  Diagnoses, symptom control, and optional diagnoses 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100630-5  Symptom 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panl Survey
  Pan Pnl Sx
  Panel Point in time  
  PANEL.SURVEY.CMS Random  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Long Common Name: Diagnoses, symptom control, and optional diagnoses [CMS Assessment]
  Fully Specified Name: Diagnoses, symptom control, and optional diagnoses: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 6
  ID: 91450
  Status (Raw): ACTIVE


85912-4   Primary diagnosis [CMS Assessment]Primary diagnosis [CMS Assessment]Primary diagnosis: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Primary diagnosis  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  Primary Diagnosis
  Long Common Name:  Primary diagnosis [CMS Assessment]

OBSERVATION ID IN FORM
M1021

FORM CODING INSTRUCTIONS
Column 1: Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided).

Column 2: ICD-10-CM and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses.

Column 3: May be completed if a Z-code is assigned to Column 2 and the underlying diagnosis is resolved.

Column 4: Complete only if the Optional Diagnosis is a multiple coding situation (for example: a manifestation code).

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249809-7  Primary diagnosis 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Random
  Dx Panl Survey
  Pan Pnl  
  Panel Point in time  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1021     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:25 PM
  Long Common Name: Primary diagnosis [CMS Assessment]
  Fully Specified Name: Primary diagnosis: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 2
  ID: 91451
  Status (Raw): ACTIVE


86255-7   Primary diagnosis ICD codePrimary diagnosis ICD codePrimary diagnosis ICD code: Type: Pt: ^Patient: Nom:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Primary diagnosis ICD code  Type  Pt  ^Patient  Nom 
  Override Display Name for Form:  Primary Diagnosis: ICD-10-code
  Long Common Name:  Primary diagnosis ICD code
  Short Name:  Primary Dx ICD code

TERM DEFINITION/DESCRIPTION(S)
  The condition that is the chief reason for providing care.
 
 

OBSERVATION ID IN FORM
M1021_A2_ICD

FORM CODING INSTRUCTIONS
Column 1: Enter the description of the diagnosis. Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided.

Column 2: Enter the ICD-10-CM code for the condition described in Column 1 - no surgical or procedure codes allowed. Codes must be entered at the level of highest specificity and ICD-10-CM coding rules and sequencing requirements must be followed. Note that external cause codes (ICD-10-CM codes beginning with V, W, X, or Y) may not be reported in M1021 (Primary Diagnosis) but may be reported in M1023 (Secondary Diagnoses). Also note that when a Z-code is reported in Column 2, the code for the underlying condition can often be entered in Column 2, as long as it is an active on-going condition impacting home health care.

BASIC ATTRIBUTES
  Class/Type: CLIN/Clinical
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Both
  Status: Active

NORMATIVE ANSWER LIST    (LL3174-1)  
 
Externally Defined: Y
Source: National Center for Health Statistics
Link to external list: http://www.cdc.gov/nchs/icd/icd10cm.htm

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  76464-7 American Physical Therapy Association registry panel
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL3174-1 NORMATIVE 1
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL3174-1 NORMATIVE 1
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL3174-1 NORMATIVE 1
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL3174-1 NORMATIVE 1
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75422-3  Primary diagnosis ICD code 
Property   LP6886-8  Type 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Fragments for synonyms   LP57597-4  ICD 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  主要诊断 ICD 代码:类型:时间点:^患者:名义型:主要诊断 ICD 代码:类型:时间点:^患者:名义型:

RELATED NAMES
  CLIN International Classification of Diseases Primary Dx ICD code
  Dx Nominal Random
  Dx ICD code Point in time Typ

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1021_A2_ICD     D 
   CMS OASIS   M1021_A2_ICD     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Primary diagnosis ICD code
  Shortname: Primary Dx ICD code
  Fully Specified Name: Primary diagnosis ICD code: Type: Pt: ^Patient: Nom:
     
  Component Word Count: 4
  ID: 91796
  Status (Raw): ACTIVE


85920-7   Symptom control rating [CMS Assessment]Symptom control rating [CMS Assessment]Symptom control rating: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Symptom control rating  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Primary Diagnosis Symptom Control Rating
  Long Common Name:  Symptom control rating [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Assessment of the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider, the degree to which each condition limits daily activities, and if symptoms are controlled by current treatments.
 
 

OBSERVATION ID IN FORM
M1023_B2_Severity - M1023_F2_Severity

FORM CODING INSTRUCTIONS
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis code is a V, W, X, Y or Z-code.

Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

NORMATIVE ANSWER LIST    (LL4489-2)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Asymptomatic, no treatment needed at this time       0       LA27597-6  
  2       Symptoms well controlled with current therapy       1       LA27598-4  
  3       Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring       2       LA27599-2  
  4       Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring       3       LA27600-8  
  5       Symptoms poorly controlled; history of re-hospitalizations       4       LA27601-6  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249874-1  Symptom control rating 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100630-5  Symptom 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment QL Survey
  Finding Qual Sx
  Findings Qualitative  
  Ordinal Random  
  Point in time Screen  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1021_A2_Severity     D 
   CMS OASIS   M1021_A2_Severity     C2 
   CMS OASIS   M1023_B2_Severity     D 
   CMS OASIS   M1023_B2_Severity     C2 
   CMS OASIS   M1023_C2_Severity     D 
   CMS OASIS   M1023_C2_Severity     C2 
   CMS OASIS   M1023_D2_Severity     D 
   CMS OASIS   M1023_D2_Severity     C2 
   CMS OASIS   M1023_E2_Severity     D 
   CMS OASIS   M1023_E2_Severity     C2 
   CMS OASIS   M1023_F2_Severity     D 
   CMS OASIS   M1023_F2_Severity     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Symptom control rating [CMS Assessment]
  Fully Specified Name: Symptom control rating: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 3
  ID: 91459
  Status (Raw): ACTIVE


85914-0   Underlying resolved condition ICD code [CMS Assessment]Underlying resolved condition ICD code [CMS Assessment]Underlying resolved condition ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Underlying resolved condition ICD code  Prid  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Optional Diagnosis: ICD-10-CM
  Long Common Name:  Underlying resolved condition ICD code [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  An underlying condition for an on-going diagnosis that has already resolved. This does not include underlying conditions for an on-going diagnosis that is also on-going; that condition can be reported as a secondary or co-morbid diagnosis.
 
 

OBSERVATION ID IN FORM
M1025_A3

FORM CODING INSTRUCTIONS
Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment.

Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when: a Z-code is reported in Column 2 AND the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated following a hysterectomy.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

NORMATIVE ANSWER LIST    (LL3174-1)  
 
Externally Defined: Y
Source: National Center for Health Statistics
Link to external list: http://www.cdc.gov/nchs/icd/icd10cm.htm

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL3174-1 NORMATIVE 1
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249873-3  Underlying resolved condition ICD code 
Property   LP6850-4  Prid   [Presence or Identity] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP57597-4  ICD 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal Survey
  Identity or presence Point in time  
  International Classification of Diseases Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1025     C2 
   CMS OASIS   M1025_A3     C2 
   CMS OASIS   M1025_B3     C2 
   CMS OASIS   M1025_C3     C2 
   CMS OASIS   M1025_D3     C2 
   CMS OASIS   M1025_E3     C2 
   CMS OASIS   M1025_F3     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Underlying resolved condition ICD code [CMS Assessment]
  Fully Specified Name: Underlying resolved condition ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 5
  ID: 91453
  Status (Raw): ACTIVE


86254-0   Underlying resolved condition.multiple coding ICD code [CMS Assessment]Underlying resolved condition.multiple coding ICD code [CMS Assessment]Underlying resolved condition.multiple coding ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Underlying resolved condition.multiple coding ICD code  Prid  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Optional Diagnosis: ICD-10-CM - multiple coding
  Long Common Name:  Underlying resolved condition.multiple coding ICD code [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Additional codes for an underlying condition for an on-going diagnosis that has already resolved. For example, a manifestation code.
 
 

OBSERVATION ID IN FORM
M1025_B4 - M1025_F4

FORM CODING INSTRUCTIONS
Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10- CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10- CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250646-9  Underlying resolved condition.multiple coding ICD code 
Property   LP6850-4  Prid   [Presence or Identity] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP35213-5  Multiple 
Fragments for synonyms   LP57597-4  ICD 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Mult Point in time
  Identity or presence Multi Random
  International Classification of Diseases Nominal Survey

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1025     C2 
   CMS OASIS   M1025_B4     C2 
   CMS OASIS   M1025_C4     C2 
   CMS OASIS   M1025_D4     C2 
   CMS OASIS   M1025_E4     C2 
   CMS OASIS   M1025_F4     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Underlying resolved condition.multiple coding ICD code [CMS Assessment]
  Fully Specified Name: Underlying resolved condition.multiple coding ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 7
  ID: 91795
  Status (Raw): ACTIVE


85913-2   Other diagnoses [CMS Assessment]Other diagnoses [CMS Assessment]Other diagnoses: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Other diagnoses  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  Other Diagnoses
  Long Common Name:  Other diagnoses [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Other/secondary/additional diagnoses that impact a patient's health
 
 

OBSERVATION ID IN FORM
M1023

QUESTION CARDINALITY
0..5

FORM CODING INSTRUCTIONS
Column 1: Diagnoses (Sequencing of diagnoses should reflect the seriousness of each condition and support the disciplines and services provided).

Column 2: ICD-10-CM and symptom control rating for each condition. Note that the sequencing of these ratings may not match the sequencing of the diagnoses.

Column 3: May be completed if a Z-code is assigned to Column 2 and the underlying diagnosis is resolved.

Column 4: Complete only if the Optional Diagnosis is a multiple coding situation (for example: a manifestation code).

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249810-5  Other diagnoses 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21049-9  Other 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Random
  Othr Panl Survey
  Pan Pnl  
  Panel Point in time  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1023     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Other diagnoses [CMS Assessment]
  Fully Specified Name: Other diagnoses: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 2
  ID: 91452
  Status (Raw): ACTIVE


81885-6   Secondary diagnosisSecondary diagnosisDiagnosis.secondary: Imp: Pt: ^Patient: Nom:  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Diagnosis.secondary  Imp  Pt  ^Patient  Nom 
  Override Display Name for Form:  Other Diagnoses: ICD-10-CM
  Long Common Name:  Secondary diagnosis
  Short Name:  Dx.secondary

OBSERVATION ID IN FORM
M1023_B2_ICD-M1023_F2_ICD

BASIC ATTRIBUTES
  Class/Type: CLIN/Clinical
  First Released in Version: 2.56
  Last Updated in Version: 2.56
  Order vs. Obs.: Observation
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  76464-7 American Physical Therapy Association registry panel
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP212525-2  Diagnosis.secondary   [Secondary diagnosis] 
Property   LP6819-9  Imp   [Impression/interpretation of study] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 

LANGUAGE VARIANTS
  Chinese (CHINA)  (From: Regenstrief-generated full translation based on part translation provided by Lin Zhang, A LOINC volunteer from China)
 
  诊断.次要:印象:时间点:^患者:名义型:诊断.次要:印象:时间点:^患者:名义型:
  Italian (ITALY)  (From: Regenstrief-generated full translation based on part translation provided by Consiglio Nazionale delle Ricerche)
 
  Diagnosi.secondaria:Imp:Pt:^Paziente:Nom:Diagnosi.secondaria:Imp:Pt:^Paziente:Nom:

RELATED NAMES
  CLIN Impression/interpretation of study Nominal
  Dx Impressions Point in time
  Dx.secondary Interp Random
  Impression Interpretation  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1023_B2_ICD     D 
   CMS OASIS   M1023_B2_ICD     C2 
   CMS OASIS   M1023_C2_ICD     D 
   CMS OASIS   M1023_C2_ICD     C2 
   CMS OASIS   M1023_D2_ICD     D 
   CMS OASIS   M1023_D2_ICD     C2 
   CMS OASIS   M1023_E2_ICD     D 
   CMS OASIS   M1023_E2_ICD     C2 
   CMS OASIS   M1023_F2_ICD     D 
   CMS OASIS   M1023_F2_ICD     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Secondary diagnosis
  Shortname: Dx.secondary
  Fully Specified Name: Diagnosis.secondary: Imp: Pt: ^Patient: Nom:
     
  Component Word Count: 2
  ID: 86206
  Status (Raw): ACTIVE


85920-7   Symptom control rating [CMS Assessment]Symptom control rating [CMS Assessment]Symptom control rating: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Symptom control rating  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Other Diagnoses Symptom Control Rating
  Long Common Name:  Symptom control rating [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Assessment of the degree of symptom control includes review of presenting signs and symptoms, type and number of medications, frequency of treatment readjustments, and frequency of contact with health care provider, the degree to which each condition limits daily activities, and if symptoms are controlled by current treatments.
 
 

OBSERVATION ID IN FORM
M1023_B2_Severity-M1023_F2_Severity

FORM CODING INSTRUCTIONS
Rate the degree of symptom control for the condition listed in Column 1. Do not assign a symptom control rating if the diagnosis code is a V, W, X, Y or Z-code.

Note that the rating for symptom control in Column 2 should not be used to determine the sequencing of the diagnoses listed in Column 1. These are separate items and sequencing may not coincide.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

NORMATIVE ANSWER LIST    (LL4489-2)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Asymptomatic, no treatment needed at this time       0       LA27597-6  
  2       Symptoms well controlled with current therapy       1       LA27598-4  
  3       Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring       2       LA27599-2  
  4       Symptoms poorly controlled; patient needs frequent adjustment in treatment and dose monitoring       3       LA27600-8  
  5       Symptoms poorly controlled; history of re-hospitalizations       4       LA27601-6  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249874-1  Symptom control rating 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100630-5  Symptom 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment QL Survey
  Finding Qual Sx
  Findings Qualitative  
  Ordinal Random  
  Point in time Screen  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1021_A2_Severity     D 
   CMS OASIS   M1021_A2_Severity     C2 
   CMS OASIS   M1023_B2_Severity     D 
   CMS OASIS   M1023_B2_Severity     C2 
   CMS OASIS   M1023_C2_Severity     D 
   CMS OASIS   M1023_C2_Severity     C2 
   CMS OASIS   M1023_D2_Severity     D 
   CMS OASIS   M1023_D2_Severity     C2 
   CMS OASIS   M1023_E2_Severity     D 
   CMS OASIS   M1023_E2_Severity     C2 
   CMS OASIS   M1023_F2_Severity     D 
   CMS OASIS   M1023_F2_Severity     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Symptom control rating [CMS Assessment]
  Fully Specified Name: Symptom control rating: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 3
  ID: 91459
  Status (Raw): ACTIVE


85914-0   Underlying resolved condition ICD code [CMS Assessment]Underlying resolved condition ICD code [CMS Assessment]Underlying resolved condition ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Underlying resolved condition ICD code  Prid  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Optional Diagnosis: ICD-10-CM
  Long Common Name:  Underlying resolved condition ICD code [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  An underlying condition for an on-going diagnosis that has already resolved. This does not include underlying conditions for an on-going diagnosis that is also on-going; that condition can be reported as a secondary or co-morbid diagnosis.
 
 

OBSERVATION ID IN FORM
M1025_B3-M1025_F3

FORM CODING INSTRUCTIONS
Column 3: (OPTIONAL) There is no requirement that HHAs enter a diagnosis code in M1025 (Columns 3 and 4). Diagnoses reported in M1025 will not impact payment.

Agencies may choose to report an underlying condition in M1025 (Columns 3 and 4) when: a Z-code is reported in Column 2 AND the underlying condition for the Z-code in Column 2 is a resolved condition. An example of a resolved condition is uterine cancer that is no longer being treated following a hysterectomy.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

NORMATIVE ANSWER LIST    (LL3174-1)  
 
Externally Defined: Y
Source: National Center for Health Statistics
Link to external list: http://www.cdc.gov/nchs/icd/icd10cm.htm

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL3174-1 NORMATIVE 1
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL3174-1 NORMATIVE 1
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249873-3  Underlying resolved condition ICD code 
Property   LP6850-4  Prid   [Presence or Identity] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP57597-4  ICD 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal Survey
  Identity or presence Point in time  
  International Classification of Diseases Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1025     C2 
   CMS OASIS   M1025_A3     C2 
   CMS OASIS   M1025_B3     C2 
   CMS OASIS   M1025_C3     C2 
   CMS OASIS   M1025_D3     C2 
   CMS OASIS   M1025_E3     C2 
   CMS OASIS   M1025_F3     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Underlying resolved condition ICD code [CMS Assessment]
  Fully Specified Name: Underlying resolved condition ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 5
  ID: 91453
  Status (Raw): ACTIVE


86254-0   Underlying resolved condition.multiple coding ICD code [CMS Assessment]Underlying resolved condition.multiple coding ICD code [CMS Assessment]Underlying resolved condition.multiple coding ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Underlying resolved condition.multiple coding ICD code  Prid  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Optional Diagnosis: ICD-10-CM - multiple coding
  Long Common Name:  Underlying resolved condition.multiple coding ICD code [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Additional codes for an underlying condition for an on-going diagnosis that has already resolved. For example, a manifestation code.
 
 

OBSERVATION ID IN FORM
M1025_B4 - M1025_F4

FORM CODING INSTRUCTIONS
Column 4: (OPTIONAL) If a Z-code is reported in M1021/M1023 (Column 2) and the agency chooses to report a resolved underlying condition that requires multiple diagnosis codes under ICD-10-CM coding guidelines, enter the diagnosis descriptions and the ICD-10-CM codes in the same row in Columns 3 and 4. For example, if the resolved condition is a manifestation code, record the diagnosis description and ICD-10- CM code for the underlying condition in Column 3 of that row and the diagnosis description and ICD-10- CM code for the manifestation in Column 4 of that row. Otherwise, leave Column 4 blank in that row.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250646-9  Underlying resolved condition.multiple coding ICD code 
Property   LP6850-4  Prid   [Presence or Identity] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP35213-5  Multiple 
Fragments for synonyms   LP57597-4  ICD 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Mult Point in time
  Identity or presence Multi Random
  International Classification of Diseases Nominal Survey

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1025     C2 
   CMS OASIS   M1025_B4     C2 
   CMS OASIS   M1025_C4     C2 
   CMS OASIS   M1025_D4     C2 
   CMS OASIS   M1025_E4     C2 
   CMS OASIS   M1025_F4     C2 

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Underlying resolved condition.multiple coding ICD code [CMS Assessment]
  Fully Specified Name: Underlying resolved condition.multiple coding ICD code: Prid: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 7
  ID: 91795
  Status (Raw): ACTIVE


46466-9   Therapeutic substance administered at home [CMS Assessment]Therapeutic substance administered at home [CMS Assessment]Therapeutic substance administered at home: Find: Pt: ^Patient: Nom: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Therapeutic substance administered at home  Find  Pt  ^Patient  Nom  CMS Assessment
  Override Display Name for Form:  Therapies the patient receives at home
  Long Common Name:  Therapeutic substance administered at home [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Identifies whether the patient is receiving intravenous, parenteral nutrition, or enteral nutrition therapy at home.
 
 

OBSERVATION ID IN FORM
M1030

ANSWER CARDINALITY
1..3

FORM CODING INSTRUCTIONS
Mark all that apply

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Added to the Component to clarify the concept.

NORMATIVE ANSWER LIST    (LL254-4)  
 
Source: 
  SEQ#        Answer        Code         Answer ID    
  1       Intravenous or infusion therapy (excludes TPN)       1       LA6244-3  
  2       Parenteral nutrition (TPN or lipids)       2       LA6321-9  
  3       Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)       3       LA6194-0  
  4       None of the above       4       LA9-3  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  46462-8 Outcome and assessment information set (OASIS) form - version B1
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP253568-2  Therapeutic substance administered at home 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7750-5  Nom 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20778-4  Substance 
Fragments for synonyms   LP21090-3  Therapeutic 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Nominal Subs
  Finding Point in time Survey
  Findings Random Ther

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1030     D 
   CMS OASIS   M1030     C2 

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Attachment Units Required: N
  Long Common Name: Therapeutic substance administered at home [CMS Assessment]
  Fully Specified Name: Therapeutic substance administered at home: Find: Pt: ^Patient: Nom: CMS Assessment
     
  Component Word Count: 5
  ID: 39902
  Status (Raw): ACTIVE


86247-4   Sensory status - follow-up [CMS Assessment]Sensory status - follow-up [CMS Assessment]Sensory status - follow-up: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Sensory status - follow-up  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  SENSORY STATUS
  Long Common Name:  Sensory status - follow-up [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP250638-6  Sensory status - follow-up 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Point in time
  Pan Panl Random
  Panel Pnl Survey

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:26 PM
  Long Common Name: Sensory status - follow-up [CMS Assessment]
  Fully Specified Name: Sensory status - follow-up: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 4
  ID: 91788
  Status (Raw): ACTIVE


57215-6   Vision [CMS Assessment]Vision [CMS Assessment]Vision: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Vision  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Vision (with corrective lenses if the patient usually wears them)
  Long Common Name:  Vision [CMS Assessment]

OBSERVATION ID IN FORM
M1200

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL784-0)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Normal vision: sees adequately in most situations; can see medication labels, newsprint.       0       LA12168-3  
  2       Partially impaired: cannot see medication labels or newsprint, but can see obstacles in path, and the surrounding layout; can count fingers at arm's length.       1       LA12169-1  
  3       Severely impaired: cannot locate objects without hearing or touching them or patient nonresponsive.       2       LA6375-5  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75855-4  Vision 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Random
  Finding QL Screen
  Findings Qual Survey
  Ordinal Qualitative  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1200     D 
   CMS OASIS   M1200     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Vision [CMS Assessment]
  Fully Specified Name: Vision: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 1
  ID: 51846
  Status (Raw): ACTIVE


57220-6   Frequency of pain interfering with activity or movement [CMS Assessment]Frequency of pain interfering with activity or movement [CMS Assessment]Frequency of pain interfering with activity or movement: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Frequency of pain interfering with activity or movement  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Frequency of pain interfering with patient's activity or movement
  Long Common Name:  Frequency of pain interfering with activity or movement [CMS Assessment]

OBSERVATION ID IN FORM
M1242

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed Property to NRat because this is a frequency term; Changed Property from NRat to Find because the answer list does not reflect Nrat.

NORMATIVE ANSWER LIST    (LL789-9)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  0       Patient has no pain       0       LA12189-9  
  1       Patient has pain that does not interfere with activity or movement       1       LA12190-7  
  2       Less often than daily       2       LA6249-2  
  3       Daily, but not constantly       3       LA6177-5  
  4       All of the time       4       LA6154-4  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP98018-2  Frequency of pain interfering with activity or movement 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21325-3  Activity 

RELATED NAMES
  Activ Movements Qualitative
  Actvty Ordinal Random
  Centers for Medicare and Medicaid Assessment Point in time Screen
  Finding QL Survey
  Findings Qual  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1242     D 
   CMS OASIS   M1242     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Frequency of pain interfering with activity or movement [CMS Assessment]
  Fully Specified Name: Frequency of pain interfering with activity or movement: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 8
  ID: 51852
  Status (Raw): ACTIVE


86248-2   OASIS C2 - Integumentary status - follow-up [CMS Assessment]OASIS C2 - Integumentary status - follow-up [CMS Assessment]OASIS C2 - Integumentary status - follow-up: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
OASIS C2 - Integumentary status - follow-up  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  INTEGUMENTARY STATUS
  Long Common Name:  OASIS C2 - Integumentary status - follow-up [CMS Assessment]

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.63
  Order vs. Obs.: Subset
  Status: Active

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP249829-5  OASIS C2 - Integumentary status - follow-up 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP57618-8  OASIS 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment PANEL.SURVEY.CMS Random
  Outcome and assessment information set Panl Survey
  Pan Pnl  
  Panel Point in time  

CHANGE HISTORY
  Change Type: ADD

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Long Common Name: OASIS C2 - Integumentary status - follow-up [CMS Assessment]
  Fully Specified Name: OASIS C2 - Integumentary status - follow-up: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 6
  ID: 91789
  Status (Raw): ACTIVE


85918-1   Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]Unhealed pressure injury at stage 2 or higher or designated as unstageable: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Unhealed pressure injury at stage 2 or higher or designated as unstageable  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as Unstageable?
  Long Common Name:  Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Excludes Stage 1 pressure inuries and all healed pressure ulcers/injuries.
 
 

OBSERVATION ID IN FORM
M1306

FORM CODING INSTRUCTIONS
Excludes Stage 1 pressure ulcers and healed Stage 2 pressure ulcers.

SKIP LOGIC
If 0, go to M1322.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.63
  Last Updated in Version: 2.64
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL251-0)  
 
Source: Regenstrief LOINC
  SEQ#        Answer        Code         Answer ID    
  1       No
http://snomed.info/sct ©: 373067005 No (qualifier value)    
  0       LA32-8  
  2       Yes
http://snomed.info/sct ©: 373066001 Yes (qualifier value)    
  1       LA33-6  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263729-8  Unhealed pressure injury at stage 2 or higher or designated as unstageable 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 
Fragments for synonyms   LP57601-4  As 

RELATED NAMES
  Arterial Stenosis Point in time Qualitative
  Centers for Medicare and Medicaid Assessment pressure injury Random
  Finding Pressure ulcer Screen
  Findings Pressure Ulcers Survey
  II QL Ulcer
  Ordinal Qual  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1306     D 
   CMS OASIS   M1306     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Long Common Name: Unhealed pressure injury at stage 2 or higher or designated as unstageable [CMS Assessment]
  Fully Specified Name: Unhealed pressure injury at stage 2 or higher or designated as unstageable: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 12
  ID: 91457
  Status (Raw): ACTIVE


86270-6   Current number of unhealed pressure injuries at each stage - follow-up or discharge [CMS Assessment]Current number of unhealed pressure injuries at each stage - follow-up or discharge [CMS Assessment]Current number of unhealed pressure injuries at each stage - follow-up or discharge: -: Pt: ^Patient: -: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Current number of unhealed pressure injuries at each stage - follow-up or discharge  Pt  ^Patient  CMS Assessment
  Override Display Name for Form:  Current Number of Unhealed Pressure Ulcers at Each Stage
  Long Common Name:  Current number of unhealed pressure injuries at each stage - follow-up or discharge [CMS Assessment]

OBSERVATION ID IN FORM
M0300

BASIC ATTRIBUTES
  Class/Type: PANEL.SURVEY.CMS/Survey
  Panel Type: Organizer
  First Released in Version: 2.63
  Last Updated in Version: 2.64
  Order vs. Obs.: Subset
  Status: Active.
Change Reason: Removed "OASIS C2" to use term in the MDS; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP266926-7  Current number of unhealed pressure injuries at each stage - follow-up or discharge 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7747-1 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100598-4  Discharge 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP21059-8  Panel 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Panel Pressure ulcer
  Disch PANEL.SURVEY.CMS Pressure Ulcers
  No Panl Random
  Num Pnl Survey
  Pan Point in time  

RELATED CODES
Code System Code Code Text Code Version
   CMS MDS   M0300     1.17.1 
   CMS MDS   M0300     1.16.1 
   CMS MDS   M0300     1.15.1 
   CMS MDS   M0300     1.14.1 
   CMS OASIS   M0300     C2 

CHANGE HISTORY
  Change Type: NAM

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Long Common Name: Current number of unhealed pressure injuries at each stage - follow-up or discharge [CMS Assessment]
  Fully Specified Name: Current number of unhealed pressure injuries at each stage - follow-up or discharge: -: Pt: ^Patient: -: CMS Assessment
     
  Component Word Count: 13
  ID: 91811
  Status (Raw): ACTIVE


55124-2   Number of pressure injuries - stage 2 [CMS Assessment]Number of pressure injuries - stage 2 [CMS Assessment]Number of pressure injuries - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 2  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of Stage 2 pressure ulcers
  Long Common Name:  Number of pressure injuries - stage 2 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 2 pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.
 
 

OBSERVATION ID IN FORM
M1311A1

FORM CONTEXT
Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.

SKIP LOGIC
If 0, at FU/DC Go to M1311B1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263748-8  Number of pressure injuries - stage 2 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  II Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300B1     2.0 
   CMS IRF-PAI   M0300B1     3.0 
   CMS IRF-PAI   M0300B1     1.5 
   CMS IRF-PAI   M0300B1     1.4 
   CMS LCDS   M0300B1     3.00 
   CMS LCDS   M0300B1     4.00 
   CMS MDS   M0300B1     1.16.1 
   CMS MDS   M0300B1     1.15.1 
   CMS MDS   M0300B1     1.14.1 
   CMS MDS   M0300B1     1.17.1 
   CMS OASIS   M1311A1     D 
   CMS OASIS   M1311A1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 2 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 6
  ID: 49485
  Status (Raw): ACTIVE


54886-7   Number of pressure injuries present upon admission/​reentry - stage 2 [CMS Assessment]Number of pressure injuries present upon admission/​reentry - stage 2 [CMS Assessment]Number of pressure injuries present upon admission &or reentry - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - stage 2  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 2 [CMS Assessment]

OBSERVATION ID IN FORM
M1311A2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263732-2  Number of pressure injuries present upon admission &or reentry - stage 2   [Number of pressure injuries present upon admission/reentry - stage 2] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP20740-4 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  II Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300B2     2.0 
   CMS IRF-PAI   M0300B2     3.0 
   CMS IRF-PAI   M0300B2     1.5 
   CMS IRF-PAI   M0300B2     1.4 
   CMS LCDS   M0300B2     3.00 
   CMS LCDS   M0300B2     4.00 
   CMS MDS   M0300B2     1.16.1 
   CMS MDS   M0300B2     1.15.1 
   CMS MDS   M0300B2     1.14.1 
   CMS MDS   M0300B2     1.17.1 
   CMS OASIS   M1311A2     D 
   CMS OASIS   M1311A2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - stage 2 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - stage 2: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 11
  ID: 49222
  Status (Raw): ACTIVE


55125-9   Number of pressure injuries - stage 3 [CMS Assessment]Number of pressure injuries - stage 3 [CMS Assessment]Number of pressure injuries - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 3  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of Stage 3 pressure ulcers
  Long Common Name:  Number of pressure injuries - stage 3 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 3 pressure ulcer is defined as 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.
 
 

OBSERVATION ID IN FORM
M1311B1

FORM CONTEXT
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.

SKIP LOGIC
If 0 at FU/DC Go to M1311C1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263749-6  Number of pressure injuries - stage 3 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  III Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300C1     2.0 
   CMS IRF-PAI   M0300C1     3.0 
   CMS IRF-PAI   M0300C1     1.5 
   CMS IRF-PAI   M0300C1     1.4 
   CMS LCDS   M0300C1     3.00 
   CMS LCDS   M0300C1     4.00 
   CMS MDS   M0300C1     1.16.1 
   CMS MDS   M0300C1     1.15.1 
   CMS MDS   M0300C1     1.14.1 
   CMS MDS   M0300C1     1.17.1 
   CMS OASIS   M1311B1     D 
   CMS OASIS   M1311B1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 3 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 6
  ID: 49486
  Status (Raw): ACTIVE


54887-5   Number of pressure injuries present upon admission/​reentry - stage 3 [CMS Assessment]Number of pressure injuries present upon admission/​reentry - stage 3 [CMS Assessment]Number of pressure injuries present upon admission &or reentry - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - stage 3  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 3 [CMS Assessment]

OBSERVATION ID IN FORM
M1311B2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263733-0  Number of pressure injuries present upon admission &or reentry - stage 3   [Number of pressure injuries present upon admission/reentry - stage 3] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21267-7 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Quant
  Cnt Point in time Quantitative
  Count Pressure ulcer Random
  III Pressure Ulcers Survey
  No QNT  
  Num Quan  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300C2     2.0 
   CMS IRF-PAI   M0300C2     3.0 
   CMS IRF-PAI   M0300C2     1.5 
   CMS IRF-PAI   M0300C2     1.4 
   CMS LCDS   M0300C2     3.00 
   CMS LCDS   M0300C2     4.00 
   CMS MDS   M0300C2     1.16.1 
   CMS MDS   M0300C2     1.15.1 
   CMS MDS   M0300C2     1.14.1 
   CMS MDS   M0300C2     1.17.1 
   CMS OASIS   M1311B2     D 
   CMS OASIS   M1311B2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - stage 3 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - stage 3: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 11
  ID: 49223
  Status (Raw): ACTIVE


55126-7   Number of pressure injuries - stage 4 [CMS Assessment]Number of pressure injuries - stage 4 [CMS Assessment]Number of pressure injuries - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 4  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of Stage 4 pressure ulcers
  Long Common Name:  Number of pressure injuries - stage 4 [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 4 pressure ulcer is defined as 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.
 
 

OBSERVATION ID IN FORM
M1311C1

FORM CONTEXT
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.

SKIP LOGIC
If 0, at FU/DC Go to M1311D1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263750-4  Number of pressure injuries - stage 4 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300D1     2.0 
   CMS IRF-PAI   M0300D1     3.0 
   CMS IRF-PAI   M0300D1     1.5 
   CMS IRF-PAI   M0300D1     1.4 
   CMS LCDS   M0300D1     3.00 
   CMS LCDS   M0300D1     4.00 
   CMS MDS   M0300D1     1.16.1 
   CMS MDS   M0300D1     1.15.1 
   CMS MDS   M0300D1     1.14.1 
   CMS MDS   M0300D1     1.17.1 
   CMS OASIS   M1311C1     D 
   CMS OASIS   M1311C1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:27 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 4 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 6
  ID: 49487
  Status (Raw): ACTIVE


54890-9   Number of pressure injuries present upon admission/​reentry - stage 4 [CMS Assessment]Number of pressure injuries present upon admission/​reentry - stage 4 [CMS Assessment]Number of pressure injuries present upon admission &or reentry - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - stage 4  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - stage 4 [CMS Assessment]

OBSERVATION ID IN FORM
M1311C2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263734-8  Number of pressure injuries present upon admission &or reentry - stage 4   [Number of pressure injuries present upon admission/reentry - stage 4] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300D2     2.0 
   CMS IRF-PAI   M0300D2     3.0 
   CMS IRF-PAI   M0300D2     1.5 
   CMS IRF-PAI   M0300D2     1.4 
   CMS LCDS   M0300D2     3.00 
   CMS LCDS   M0300D2     4.00 
   CMS MDS   M0300D2     1.16.1 
   CMS MDS   M0300D2     1.15.1 
   CMS MDS   M0300D2     1.14.1 
   CMS MDS   M0300D2     1.17.1 
   CMS OASIS   M1311C2     D 
   CMS OASIS   M1311C2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - stage 4 [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - stage 4: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 11
  ID: 49227
  Status (Raw): ACTIVE


54893-3   Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]Number of pressure injuries - unstageable due to non-removable dressing or device: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - unstageable due to non-removable dressing or device  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of unstageable pressure ulcers due to non-removable dressing/device
  Long Common Name:  Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A pressure ulcer that is unstageable due to a non-removable dressing is defined as a known pressure ulcer that is covered by a non-removable dressing or device, such as a surgical dressing, cast, other orthopedic device, or dressing not to be removed per physician's order.
 
 

OBSERVATION ID IN FORM
M1311D1

FORM CONTEXT
Unstageable: Non-removable dressing: Known but not stageable due to non-removable dressing/device.

SKIP LOGIC
If 0, at FU/DC Go to M1311E1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt".; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263735-5  Number of pressure injuries - unstageable due to non-removable dressing or device 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300E1     2.0 
   CMS IRF-PAI   M0300E1     3.0 
   CMS IRF-PAI   M0300E1     1.5 
   CMS IRF-PAI   M0300E1     1.4 
   CMS LCDS   M0300E1     3.00 
   CMS LCDS   M0300E1     4.00 
   CMS MDS   M0300E1     1.16.1 
   CMS MDS   M0300E1     1.15.1 
   CMS MDS   M0300E1     1.14.1 
   CMS MDS   M0300E1     1.17.1 
   CMS OASIS   M1311D1     D 
   CMS OASIS   M1311D1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - unstageable due to non-removable dressing or device [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - unstageable due to non-removable dressing or device: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 12
  ID: 49230
  Status (Raw): ACTIVE


54894-1   Number of pressure injuries present upon admission/​reentry - unstageable due to non-removable dressing [CMS Assessment]Number of pressure injuries present upon admission/​reentry - unstageable due to non-removable dressing [CMS Assessment]Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing [CMS Assessment]

OBSERVATION ID IN FORM
M1311D2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263736-3  Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing   [Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300E2     2.0 
   CMS IRF-PAI   M0300E2     3.0 
   CMS IRF-PAI   M0300E2     1.5 
   CMS IRF-PAI   M0300E2     1.4 
   CMS LCDS   M0300E2     3.00 
   CMS LCDS   M0300E2     4.00 
   CMS MDS   M0300E2     1.16.1 
   CMS MDS   M0300E2     1.15.1 
   CMS MDS   M0300E2     1.14.1 
   CMS MDS   M0300E2     1.17.1 
   CMS OASIS   M1311D2     D 
   CMS OASIS   M1311D2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 15
  ID: 49231
  Status (Raw): ACTIVE


54946-9   Number of pressure injuries - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
  Long Common Name:  Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  Slough tissue is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Eschar tissue is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike.
 
 

OBSERVATION ID IN FORM
M1311E1

FORM CONTEXT
Unstageable: Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

SKIP LOGIC
If 0, at FU/DC Go to M1311F1

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt";Updated COMPONENT from "and or" to "&or" to match convention; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86870-3 MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88279-5 MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88951-9 MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  90480-5 MDS v3.0 - RAI v1.17.1 - Interim Payment Assessment (IPA) item set [CMS Assessment]
  90481-3 MDS v3.0 - RAI v1.17.1 - Optional State Assessment (OSA) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263737-1  Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar   [Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300F1     2.0 
   CMS IRF-PAI   M0300F1     3.0 
   CMS IRF-PAI   M0300F1     1.5 
   CMS IRF-PAI   M0300F1     1.4 
   CMS LCDS   M0300F1     3.00 
   CMS LCDS   M0300F1     4.00 
   CMS MDS   M0300F1     1.16.1 
   CMS MDS   M0300F1     1.15.1 
   CMS MDS   M0300F1     1.14.1 
   CMS MDS   M0300F1     1.17.1 
   CMS OASIS   M1311E1     D 
   CMS OASIS   M1311E1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 15
  ID: 49287
  Status (Raw): ACTIVE


54947-7   Number of pressure injuries present upon admission/​reentry - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries present upon admission/​reentry - unstageable due to coverage of wound bed by slough/​eschar [CMS Assessment]Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]

OBSERVATION ID IN FORM
M1311E2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263738-9  Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar   [Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT  
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300F2     2.0 
   CMS IRF-PAI   M0300F2     3.0 
   CMS IRF-PAI   M0300F2     1.5 
   CMS IRF-PAI   M0300F2     1.4 
   CMS LCDS   M0300F2     3.00 
   CMS LCDS   M0300F2     4.00 
   CMS MDS   M0300F2     1.16.1 
   CMS MDS   M0300F2     1.15.1 
   CMS MDS   M0300F2     1.14.1 
   CMS MDS   M0300F2     1.17.1 
   CMS OASIS   M1311E2     D 
   CMS OASIS   M1311E2     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 20
  ID: 49288
  Status (Raw): ACTIVE


54950-1   Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - unstageable with suspected deep tissue injury in evolution  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of unstageable pressure ulcers with suspected deep tissue injury in evolution
  Long Common Name:  Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A pressure ulcer that is unstageable due to deep tissue injury has purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
 
 

OBSERVATION ID IN FORM
M1311F1

FORM CONTEXT
Unstageable: Deep tissue injury: Suspected deep tissue injury in evolution

SKIP LOGIC
If 0, Go to M1322

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt"; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85645-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263739-7  Number of pressure injuries - unstageable with suspected deep tissue injury in evolution 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT Ulcer
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300G1     2.0 
   CMS IRF-PAI   M0300G1     3.0 
   CMS IRF-PAI   M0300G1     1.5 
   CMS IRF-PAI   M0300G1     1.4 
   CMS LCDS   M0300G1     3.00 
   CMS LCDS   M0300G1     4.00 
   CMS MDS   M0300G1     1.16.1 
   CMS MDS   M0300G1     1.15.1 
   CMS MDS   M0300G1     1.14.1 
   CMS MDS   M0300G1     1.17.1 
   CMS OASIS   M1311F1     D 
   CMS OASIS   M1311F1     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - unstageable with suspected deep tissue injury in evolution [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 12
  ID: 49291
  Status (Raw): ACTIVE


54951-9   Number of pressure injuries present upon admission/​reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries present upon admission/​reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution  Num  Pt  ^Patient  Qn  CMS Assessment
  Override Display Name for Form:  Number of these unstageable pressure ulcers that were present at most recent SOC/ROC
  Long Common Name:  Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]

OBSERVATION ID IN FORM
M1311F2

FORM CODING INSTRUCTIONS
Enter how many were noted at the time of most recent SOC/ROC

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.27
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  54580-6 Minimum Data Set - version 3.0
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  69412-5 Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
  83265-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
  85662-5 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
  85668-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  86522-0 MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  86856-2 MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
  86871-1 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  86872-9 MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  86873-7 MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  86876-0 MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
  86877-8 MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  87414-9 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
  87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 [CMS Assessment]
  87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 [CMS Assessment]
  88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88283-7 MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88284-5 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88285-2 MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88286-0 MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88287-8 MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88288-6 MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88292-8 MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  88329-8 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88945-1 MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
  88946-9 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
  88947-7 MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
  88948-5 MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  88949-3 MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
  88950-1 MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
  88954-3 MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  88955-0 MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 [CMS Assessment]
  90473-0 MDS v3.0 - RAI v1.17.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
  90474-8 MDS v3.0 - RAI v1.17.1 - Nursing home PPS (NP) item set [CMS Assessment]
  90475-5 MDS v3.0 - RAI v1.17.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
  90476-3 MDS v3.0 - RAI v1.17.1 - Swing bed PPS (SP) item set [CMS Assessment]
  90477-1 MDS v3.0 - RAI v1.17.1 - Nursing home discharge (ND) item set [CMS Assessment]
  90478-9 MDS v3.0 - RAI v1.17.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
  91552-0 MDS v3.0 - RAI v1.17.1 - Swing bed discharge (SD) item set [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263740-5  Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution   [Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution] 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7753-9  Qn 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266931-7  Pressure injuries 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Quantitative
  Cnt Pressure ulcer Random
  Count Pressure Ulcers Survey
  No QNT Ulcer
  Num Quan  
  Number Quant  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS IRF-PAI   M0300G2     2.0 
   CMS IRF-PAI   M0300G2     3.0 
   CMS IRF-PAI   M0300G2     1.5 
   CMS IRF-PAI   M0300G2     1.4 
   CMS LCDS   M0300G2     3.00 
   CMS LCDS   M0300G2     4.00 
   CMS MDS   M0300G2     1.16.1 
   CMS MDS   M0300G2     1.15.1 
   CMS MDS   M0300G2     1.14.1 
   CMS MDS   M0300G2     1.17.1 
   CMS OASIS   M1311F2     C2 
   CMS OASIS   M1311F2     D 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution [CMS Assessment]
  Fully Specified Name: Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution: Num: Pt: ^Patient: Qn: CMS Assessment
     
  Component Word Count: 17
  ID: 49292
  Status (Raw): ACTIVE


46536-9   Number of pressure injuries - stage 1 Ord [CMS Assessment]Number of pressure injuries - stage 1 Ord [CMS Assessment]Number of pressure injuries - stage 1: Num: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of pressure injuries - stage 1  Num  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Current Number of Stage 1 Pressure Ulcers
  Long Common Name:  Number of pressure injuries - stage 1 Ord [CMS Assessment]

TERM DEFINITION/DESCRIPTION(S)
  A stage 1 pressure injury is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
 
 

OBSERVATION ID IN FORM
M1322

FORM CONTEXT
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.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.19
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed SCALE to Ord because this term has a normative answer list; "Pressure ulcer" has been updated to 'pressure injury' according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL792-3)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Answer ID    
  1       0       LA6111-4  
  2       1       LA6112-2  
  3       2       LA6113-0  
  4       3       LA6114-8  
  5       4 or more       LA12206-1  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  46462-8 Outcome and assessment information set (OASIS) form - version B1 LL269-2 NORMATIVE 5
  57039-0 Outcome and assessment information set (OASIS) form - version C LL269-2 NORMATIVE 5
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL269-2 NORMATIVE 5
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL269-2 NORMATIVE 5
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL269-2 NORMATIVE 5
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL269-2 NORMATIVE 5
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL792-3 NORMATIVE 5
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL792-3 NORMATIVE 5
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL792-3 NORMATIVE 5
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL792-3 NORMATIVE 5
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL5031-1 NORMATIVE 5
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL5031-1 NORMATIVE 5
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL5031-1 NORMATIVE 5
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263731-4  Number of pressure injuries - stage 1 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP21265-1 
Fragments for synonyms   LP266931-7  Pressure injuries 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Number Qual
  Cnt Ordinal Qualitative
  Count Point in time Random
  i Pressure ulcer Screen
  No Pressure Ulcers Survey
  Num QL  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1322     D 
   CMS OASIS   M1322     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of pressure injuries - stage 1 Ord [CMS Assessment]
  Fully Specified Name: Number of pressure injuries - stage 1: Num: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 39956
  Status (Raw): ACTIVE


57231-3   Stage of most problematic pressure injury [CMS Assessment]Stage of most problematic pressure injury [CMS Assessment]Stage of most problematic pressure injury: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Stage of most problematic pressure injury  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable
  Long Common Name:  Stage of most problematic pressure injury [CMS Assessment]

OBSERVATION ID IN FORM
M1324

FORM CONTEXT
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.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

NORMATIVE ANSWER LIST    (LL4511-3)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Stage 1       1       LA6383-9  
  2       Stage 2       2       LA6384-7  
  3       Stage 3       3       LA6385-4  
  4       Stage 4       4       LA6386-2  
  5       Patient has no pressure ulcers or no stageable pressure ulcers       NA       LA27644-6  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL4511-3 NORMATIVE 5
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL4511-3 NORMATIVE 5
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4511-3 NORMATIVE 5
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4511-3 NORMATIVE 5
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL5032-9 NORMATIVE 5
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL5032-9 NORMATIVE 5
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL5032-9 NORMATIVE 5
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL5032-9 NORMATIVE 5
  

PARTS

Part Type    Part No.  Part Name   
Component   LP263724-9  Stage of most problematic pressure injury 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP266930-9  Pressure injury 
Fragments for synonyms   LP267481-2  Injury 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Pressure ulcer Screen
  Finding Pressure Ulcers Survey
  Findings QL Ulcer
  Ordinal Qual  
  Point in time Qualitative  
  pressure injury Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1324     D 
   CMS OASIS   M1324     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Stage of most problematic pressure injury [CMS Assessment]
  Fully Specified Name: Stage of most problematic pressure injury: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51864
  Status (Raw): ACTIVE


57232-1   Stasis ulcer [CMS Assessment]Stasis ulcer [CMS Assessment]Stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Stasis ulcer  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Does this patient have a Stasis Ulcer?
  Long Common Name:  Stasis ulcer [CMS Assessment]

OBSERVATION ID IN FORM
M1330

SKIP LOGIC
If 0, go to M1340. If 3, go to M1340.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms.

NORMATIVE ANSWER LIST    (LL4512-1)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       No
http://snomed.info/sct ©: 373067005 No (qualifier value)    
  0       LA32-8  
  2       Yes, patient has BOTH observable and unobservable stasis ulcers       1       LA12402-6  
  3       Yes, patient has observable stasis ulcers ONLY       2       LA12400-0  
  4       Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing/device)       3       LA12401-8  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  57039-0 Outcome and assessment information set (OASIS) form - version C LL794-9 NORMATIVE 3
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL794-9 NORMATIVE 3
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL794-9 NORMATIVE 3
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL794-9 NORMATIVE 3
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL794-9 NORMATIVE 3
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL4512-1 NORMATIVE 4
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL4512-1 NORMATIVE 4
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4512-1 NORMATIVE 4
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4512-1 NORMATIVE 4
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL4512-1 NORMATIVE 4
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL4512-1 NORMATIVE 4
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4512-1 NORMATIVE 4
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL4512-1 NORMATIVE 4
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75668-1  Stasis ulcer 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP267480-4  Ulcer 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Screen
  Finding QL Survey
  Findings Qual  
  Injury Qualitative  
  Ordinal Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1330     D 
   CMS OASIS   M1330     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Stasis ulcer [CMS Assessment]
  Fully Specified Name: Stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 51866
  Status (Raw): ACTIVE


57233-9   Number of stasis ulcers [CMS Assessment]Number of stasis ulcers [CMS Assessment]Number of stasis ulcers: Num: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Number of stasis ulcers  Num  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Current Number of Stasis Ulcer(s) that are Observable
  Long Common Name:  Number of stasis ulcers [CMS Assessment]

OBSERVATION ID IN FORM
M1332

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed SCALE from Qn to Ord because this term has an answer list.

NORMATIVE ANSWER LIST    (LL795-6)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       One       1       LA6306-0  
  2       Two       2       LA6404-3  
  3       Three       3       LA6395-3  
  4       Four or more       4       LA6200-5  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75245-8  Number of stasis ulcers 
Property   LP6841-3  Num   [Number (count)] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 

RELATED NAMES
  # stasis ulcers Number Random
  Centers for Medicare and Medicaid Assessment Ordinal Screen
  Cnt Point in time Survey
  Count QL  
  No Qual  
  Num Qualitative  

EXAMPLE UNITS
  Unit  Source Type
  {#}  EXAMPLE UCUM UNITS 

UNITS (INTERNAL DETAILS)
  Source Type:  EXAMPLE UCUM UNITS 
  Unit:  {#} 

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1332     D 
   CMS OASIS   M1332     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:28 PM
  Attachment Units Required: N
  Long Common Name: Number of stasis ulcers [CMS Assessment]
  Fully Specified Name: Number of stasis ulcers: Num: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 4
  ID: 51867
  Status (Raw): ACTIVE


57234-7   Status of most problematic stasis ulcer [CMS Assessment]Status of most problematic stasis ulcer [CMS Assessment]Status of most problematic stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Status of most problematic stasis ulcer  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Status of Most Problematic Stasis Ulcer that is Observable
  Long Common Name:  Status of most problematic stasis ulcer [CMS Assessment]

OBSERVATION ID IN FORM
M1334

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms.

NORMATIVE ANSWER LIST    (LL4513-9)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Fully granulating       1       LA6203-9  
  2       Early/partial granulation       2       LA6193-2  
  3       Not healing       3       LA6300-3  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code and, if applicable, override LOINC answer lists that are associated with this LOINC term in the context of that panel. Override lists are used when the panel requires a different answer list and/or answer list link type than the default answer list associated with this LOINC.
  LOINC   Long Common Name   Answer List Id Answer List Type   # of answers
  57039-0 Outcome and assessment information set (OASIS) form - version C LL796-4 NORMATIVE 4
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care LL796-4 NORMATIVE 4
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care LL796-4 NORMATIVE 4
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up LL796-4 NORMATIVE 4
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency LL796-4 NORMATIVE 4
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] LL4513-9 NORMATIVE 3
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] LL4513-9 NORMATIVE 3
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] LL4513-9 NORMATIVE 3
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] LL4513-9 NORMATIVE 3
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment] LL4513-9 NORMATIVE 3
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment] LL4513-9 NORMATIVE 3
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment] LL4513-9 NORMATIVE 3
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment] LL4513-9 NORMATIVE 3
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75676-4  Status of most problematic stasis ulcer 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP267480-4  Ulcer 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment Point in time Screen
  Finding QL Survey
  Findings Qual  
  Injury Qualitative  
  Ordinal Random  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1334     D 
   CMS OASIS   M1334     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:29 PM
  Attachment Units Required: N
  Long Common Name: Status of most problematic stasis ulcer [CMS Assessment]
  Fully Specified Name: Status of most problematic stasis ulcer: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 6
  ID: 51868
  Status (Raw): ACTIVE


57235-4   Surgical wound [CMS Assessment]Surgical wound [CMS Assessment]Surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Surgical wound  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Does this patient have a Surgical Wound?
  Long Common Name:  Surgical wound [CMS Assessment]

OBSERVATION ID IN FORM
M1340

SKIP LOGIC
If 0, go to M1400. If 2, go to M1400.

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.63
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL849-1)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       No
http://snomed.info/sct ©: 373067005 No (qualifier value)    
  0       LA32-8  
  2       Yes, patient has at least one observable surgical wound       1       LA12633-6  
  3       Surgical wound known but not observable due to non-removable dressing/device       2       LA12634-4  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75696-2  Surgical wound 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100628-9  Surgical 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment QL Surg
  Finding Qual Survey
  Findings Qualitative  
  Ordinal Random  
  Point in time Screen  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1340     D 
   CMS OASIS   M1340     C2 

CHANGE HISTORY
  Change Type: MIN

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:29 PM
  Attachment Units Required: N
  Long Common Name: Surgical wound [CMS Assessment]
  Fully Specified Name: Surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment
     
  Component Word Count: 2
  ID: 51869
  Status (Raw): ACTIVE


57236-2   Status of most problematic surgical wound [CMS Assessment]Status of most problematic surgical wound [CMS Assessment]Status of most problematic surgical wound: Find: Pt: ^Patient: Ord: CMS Assessment  

NAME
  Fully Specified Name: 
Component   Property   Time   System   Scale   Method
Status of most problematic surgical wound  Find  Pt  ^Patient  Ord  CMS Assessment
  Override Display Name for Form:  Status of Most Problematic Surgical Wound that is Observable
  Long Common Name:  Status of most problematic surgical wound [CMS Assessment]

OBSERVATION ID IN FORM
M1342

BASIC ATTRIBUTES
  Class/Type: SURVEY.CMS/Survey
  First Released in Version: 2.29
  Last Updated in Version: 2.61
  Order vs. Obs.: Observation
  Status: Active.
Change Reason: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

NORMATIVE ANSWER LIST    (LL796-4)  
 
Source: Centers for Medicare & Medicaid Services
  SEQ#        Answer        Code         Answer ID    
  1       Newly epithelialized       0       LA12197-2  
  2       Fully granulating       1       LA6203-9  
  3       Early/partial granulation       2       LA6193-2  
  4       Not healing       3       LA6300-3  

MEMBER OF THESE PANELS     
  This section provides information about panels that contain this LOINC code.
  LOINC   Long Common Name  
  57039-0 Outcome and assessment information set (OASIS) form - version C
  57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
  57191-9 Outcome and assessment information set (OASIS) form - version C - Resumption of Care
  57192-7 Outcome and assessment information set (OASIS) form - version C - Follow-Up
  57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
  85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
  86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
  86244-1 Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
  86264-9 Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
  88368-6 Outcome and assessment information set (OASIS) form - version D - Resumption of care [CMS Assessment]
  88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up [CMS Assessment]
  88371-0 Outcome and assessment information set (OASIS) form - version D - Discharged from agency [CMS Assessment]
  88373-6 Outcome and assessment information set (OASIS) form - version D - Start of care [CMS Assessment]
  

PARTS

Part Type    Part No.  Part Name   
Component   LP75677-2  Status of most problematic surgical wound 
Property   LP6813-2  Find   [Finding] 
Time   LP6960-1  Pt   [Point in time (spot)] 
Super System   LP6985-8  Patient 
Scale   LP7751-3  Ord 
Method   LP230524-3  CMS Assessment   [Centers for Medicare and Medicaid Assessment] 
Fragments for synonyms   LP100628-9  Surgical 

RELATED NAMES
  Centers for Medicare and Medicaid Assessment QL Surg
  Finding Qual Survey
  Findings Qualitative  
  Ordinal Random  
  Point in time Screen  

RELATED CODES
Code System Code Code Text Code Version
   CMS OASIS   M1342     D 
   CMS OASIS   M1342     C2 

CHANGE HISTORY
  Change Type: MAJ

INTERNAL FIELDS
  Detail Page Created On: 6/26/2019 1:38:29 PM
  Attachment Units Required: N
  Long Common Name: Status of most problematic surgical wound [CMS Assessment]
  Fully Specified Name: Status of most problematic surgical wound: Find: Pt: ^Patient: Ord: CMS