Do you get the help you need to get out of bed or to walk?
Do you get the help you need when you need to use the bathroom?
Do you get the help you need to clean your teeth or get dressed?
Do you get the help you need during meals?
If not, please describe.
Will update this area
No Issues/NA
Further Investigation
Do you get the help you need to get out of bed or to walk?
Do you get the help you need when you need to use the bathroom?
Do you get the help you need to clean your teeth or get dressed?
Do you get the help you need during meals?
If not, please describe.
Will update this area
No Issues/NA
Further Investigation
Do you get the help you need to get out of bed or to walk?
Do you get the help you need when you need to use the bathroom?
Do you get the help you need to clean your teeth or get dressed?
Do you get the help you need during meals?
If not, please describe.
Will update this area
No Issues/NA
Further Investigation
CAA Documentation and Care Planning Process
| MDS Item | Short Description |
| A0050 | Type of Record |
| A0100A | Facility National Provider Identifier (NPI) |
| A0100B | Facility CMS Certification Number (CCN) |
| A0100C | State provider number |
| A0200 | Type of provider |
| A0310A | Type of assessment: OBRA |
| A0310B | Type of assessment: PPS |
| A0310E | First assessment since most recent entry |
| A0310F | Entry/discharge reporting |
| A0310G | Planned/unplanned discharge |
| A0310G1 | Interrupted Stay |
| A0310H | SNF Part A PPS Discharge |
| A0410 | Unit Certification or Licensure Designation |
| A0500A | Resident first name |
| A0500B | Resident middle initial |
| A0500C | Resident last name |
| A0500D | Resident name suffix |
| A0600A | Social Security Number |
| A0600B | Medicare number |
| A0700 | Medicaid number |
| A0800 | Gender |
| A0900 | Birthdate |
| A1005A | Ethnicity: No, not of Hispanic, Latino/a, or Spanish origin |
| A1005B | Ethnicity: Yes, Mexican, Mexican American, Chicano/a |
| A1005C | Ethnicity: Yes, Puerto Rican |
| A1005D | Ethnicity: Yes, Cuban |
| A1005E | Ethnicity: Yes, another Hispanic, Latino, or Spanish origin |
| A1005X | Ethnicity: Resident unable to respond |
| A1005Y | Ethnicity: Resident declines to respond |
| A1010A | Race: White |
| A1010B | Race: Black or African American |
| A1010C | Race: American Indian or Alaska Native |
| A1010D | Race: Asian Indian |
| A1010E | Race: Chinese |
| A1010F | Race: Filipino |
| A1010G | Race: Japanese |
| A1010H | Race: Korean |
| A1010I | Race: Vietnamese |
| A1010J | Race: Other Asian |
| A1010K | Race: Native Hawaiian |
| A1010L | Race: Guamanian or Chamorro |
| A1010M | Race: Samoan |
| A1010N | Race: Other Pacific Islander |
| A1010X | Resident unable to respond |
| A1010Y | Resident declines to respond |
| A1010Z | None of the above |
| A1110A | Language: What is your preferred language? |
| A1110B | Language: Need or want an interpreter? |
| A1200 | Marital status |
| A1250A | Transportation (from NACHC©) : Yes, kept from med appts. |
| A1250B | Transportation (from NACHC©): Yes, kept from non-med appts. |
| A1250C | Transportation (from NACHC©): No |
| A1250X | Transportation (from NACHC©): Resident unable to respond |
| A1250Y | Transportation (from NACHC©): Resident declines to respond |
| A1300A | Medical record number |
| A1300B | Room number |
| A1300C | Name by which resident prefers to be addressed |
| A1300D | Lifetime occupation(s) |
| A1500 | Resident evaluated by PASRR |
| A1510A | Level II PASRR conditions: Serious Mental Illness |
| A1510B | Level II PASRR conditions: Intellectual Disability |
| A1510C | Level II PASRR conditions: Other related conditions |
| A1550A | ID/DD status: Down syndrome |
| A1550B | ID/DD status: Autism |
| A1550C | ID/DD status: Epilepsy |
| A1550D | ID/DD status: other organic ID/DD condition |
| A1550E | ID/DD status: ID/DD with no organic condition |
| A1550Z | ID/DD status: none of the above |
| A1600 | Entry date (date of admission/reentry in facility) |
| A1700 | Type of entry |
| A1805 | Entered From |
| A1900 | Admission date |
| A2000 | Discharge date |
| A2105 | Discharge Status |
| A2121 | Provision of Current Reconciled Medication List (To Provider) |
| A2122A | Route of Current Reconciled Medication List Transmission: EHR to provider |
| A2122B | Route of Current Reconciled Medication List Transmission: HIEO to provider |
| A2122C | Route of Current Reconciled Medication List Transmission: Verbal to provider |
| A2122D | Route of Current Reconciled Medication List Transmission: Paper-based to provider |
| A2122E | Route of Current Reconciled Medication List Transmission: Other Methods to provider |
| A2123 | Provision of Current Reconciled Medication List (To Resident) |
| A2124A | Route of Current Reconciled Medication List Transmission: EHR to res/fam/caregiver |
| A2124B | Route of Current Reconciled Medication List Transmission: HIEO to res/fam/caregiver |
| A2124C | Route of Current Reconciled Medication List Transmission: Verbal to res/fam/caregiver |
| A2124D | Route of Current Reconciled Medication List Transmission: Paper-based to res/fam/caregiver |
| A2124E | Route of Current Reconciled Medication List Transmission: Other Methods to res/fam/caregiver |
| A2200 | Previous assessment reference date for significant correction |
| A2300 | Assessment reference date |
| A2400A | Has resident had Medicare-covered stay |
| A2400B | Start date of most recent Medicare stay |
| A2400C | End date of most recent Medicare stay |
| B0100 | Comatose |
| B0200 | Hearing |
| B0300 | Hearing aid |
| B0600 | Speech clarity |
| B0700 | Makes self understood |
| B0800 | Ability to understand others |
| B1000 | Vision |
| B1200 | Corrective lenses |
| B1300 | Health Literacy |
| C0100 | BIMS: should resident interview be conducted |
| C0200 | BIMS res interview: repetition of three words |
| C0300A | BIMS res interview: able to report correct year |
| C0300B | BIMS res interview: able to report correct month |
| C0300C | BIMS res interview: able report correct day of week |
| C0400A | BIMS res interview: able to recall "sock" |
| C0400B | BIMS res interview: able to recall "blue" |
| C0400C | BIMS res interview: able to recall "bed" |
| C0500 | BIMS res interview: summary score |
| C0600 | Staff assessment mental status: conduct assessment |
| C0700 | Staff assessment mental status: short-term memory OK |
| C0800 | Staff assessment mental status: long-term memory OK |
| C0900A | Staff assessment mental status: recall current season |
| C0900B | Staff assessment mental status: recall location of room |
| C0900C | Staff assessment mental status: recall staff names/faces |
| C0900D | Staff assessment mental status: recall in nursing home |
| C0900Z | Staff assessment mental status: none of above recalled |
| C1000 | Cognitive skills for daily decision making |
| C1310A | Acute Onset Mental Status Change |
| C1310B | Signs of delirium: inattention |
| C1310C | Signs of delirium: disorganized thinking |
| C1310D | Signs of delirium: altered level of consciousness |
| D0100 | PHQ: should resident mood interview be conducted |
| D0150A1 | PHQ res: little interest or pleasure - presence |
| D0150A2 | PHQ res: little interest or pleasure - frequency |
| D0150B1 | PHQ res: feeling down, depressed - presence |
| D0150B2 | PHQ res: feeling down, depressed - frequency |
| D0150C1 | PHQ res: trouble with sleep - presence |
| D0150C2 | PHQ res: trouble with sleep - frequency |
| D0150D1 | PHQ res: feeling tired/little energy - presence |
| D0150D2 | PHQ res: feeling tired/little energy - frequency |
| D0150E1 | PHQ res: poor appetite or overeating - presence |
| D0150E2 | PHQ res: poor appetite or overeating - frequency |
| D0150F1 | PHQ res: feeling bad about self - presence |
| D0150F2 | PHQ res: feeling bad about self - frequency |
| D0150G1 | PHQ res: trouble concentrating - presence |
| D0150G2 | PHQ res: trouble concentrating - frequency |
| D0150H1 | PHQ res: slow, fidgety, restless - presence |
| D0150H2 | PHQ res: slow, fidgety, restless - frequency |
| D0150I1 | PHQ res: thoughts better off dead - presence |
| D0150I2 | PHQ res: thoughts better off dead - frequency |
| D0160 | PHQ res: total mood severity score |
| D0500A1 | PHQ staff: little interest or pleasure - presence |
| D0500A2 | PHQ staff: little interest or pleasure - frequency |
| D0500B1 | PHQ staff: feeling down, depressed - presence |
| D0500B2 | PHQ staff: feeling down, depressed - frequency |
| D0500C1 | PHQ staff: trouble with sleep - presence |
| D0500C2 | PHQ staff: trouble with sleep - frequency |
| D0500D1 | PHQ staff: feeling tired/little energy - presence |
| D0500D2 | PHQ staff: feeling tired/little energy - frequency |
| D0500E1 | PHQ staff: poor appetite or overeating - presence |
| D0500E2 | PHQ staff: poor appetite or overeating - frequency |
| D0500F1 | PHQ staff: feeling bad about self - presence |
| D0500F2 | PHQ staff: feeling bad about self - frequency |
| D0500G1 | PHQ staff: trouble concentrating - presence |
| D0500G2 | PHQ staff: trouble concentrating - frequency |
| D0500H1 | PHQ staff: slow, fidgety, restless - presence |
| D0500H2 | PHQ staff: slow, fidgety, restless - frequency |
| D0500I1 | PHQ staff: thoughts better off dead - presence |
| D0500I2 | PHQ staff: thoughts better off dead - frequency |
| D0500J1 | PHQ staff: short-tempered - presence |
| D0500J2 | PHQ staff: short-tempered - frequency |
| D0600 | PHQ staff: total mood severity score |
| D0700 | Social Isolation |
| E0100A | Psychosis: hallucinations |
| E0100B | Psychosis: delusions |
| E0100Z | Psychosis: none of the above |
| E0200A | Physical behavioral symptoms directed toward others |
| E0200B | Verbal behavioral symptoms directed toward others |
| E0200C | Other behavioral symptoms not directed toward others |
| E0300 | Overall presence of behavioral symptoms |
| E0500A | Behavioral symptoms put res at risk for illness/injury |
| E0500B | Behavioral symptoms interfere with resident care |
| E0500C | Behavioral symptoms interfere with social activities |
| E0600A | Behavioral symptoms put others at risk for injury |
| E0600B | Behavioral symptoms intrude on privacy of others |
| E0600C | Behavioral symptoms disrupt care or living environment |
| E0800 | Rejection of care: presence and frequency |
| E0900 | Wandering: presence and frequency |
| E1000A | Wandering: risk of getting to dangerous place |
| E1000B | Wandering: intrude on privacy of others |
| E1100 | Change in behavior or other symptoms |
| F0300 | Conduct res interview for daily/activity preferences |
| F0400A | Res interview: choose clothes to wear |
| F0400B | Res interview: take care of personal belongings |
| F0400C | Res interview: choose tub, bath, shower, sponge |
| F0400D | Res interview: have snacks between meals |
| F0400E | Res interview: choose own bedtime |
| F0400F | Res interview: discuss care with family/friend |
| F0400G | Res interview: use phone in private |
| F0400H | Res interview: lock things to keep them safe |
| F0500A | Res interview: have books, newspaper, mags to read |
| F0500B | Res interview: listen to music |
| F0500C | Res interview: be around animals/pets |
| F0500D | Res interview: keep up with news |
| F0500E | Res interview: do things with groups of people |
| F0500F | Res interview: do favorite activities |
| F0500G | Res interview: go outside when good weather |
| F0500H | Res interview: participate in religious practices |
| F0600 | Primary respondent: daily/activities prefs |
| F0700 | Conduct staff assessment for daily/activity prefs |
| F0800A | Staff assessment: choosing clothes to wear |
| F0800B | Staff assessment: caring for personal belongings |
| F0800C | Staff assessment: receiving tub bath |
| F0800D | Staff assessment: receiving shower |
| F0800E | Staff assessment: receiving bed bath |
| F0800F | Staff assessment: receiving sponge bath |
| F0800G | Staff assessment: snacks between meals |
| F0800H | Staff assessment: staying up past 8PM |
| F0800I | Staff assessment: discuss care with family/other |
| F0800J | Staff assessment: use phone in private |
| F0800K | Staff assessment: place to lock personal things |
| F0800L | Staff assessment: reading books, newspapers, mags |
| F0800M | Staff assessment: listening to music |
| F0800N | Staff assessment: being around animals/pets |
| F0800O | Staff assessment: keeping up with news |
| F0800P | Staff assessment: doing things with groups |
| F0800Q | Staff assessment: participating in favorite activities |
| F0800R | Staff assessment: spend time away from nursing home |
| F0800S | Staff assessment: spend time outdoors |
| F0800T | Staff assessment: participating in religious activities |
| F0800Z | Staff assessment: none of above activities |
| GG0100A | Self-Care: Prior Function |
| GG0100B | Indoor Mobility (Ambulation): Prior Function |
| GG0100C | Stairs: Prior Function |
| GG0100D | Functional Cognition: Prior Function |
| GG0110A | Manual wheelchair |
| GG0110B | Motorized wheelchair and/or scooter |
| GG0110C | Mechanical lift |
| GG0110D | Walker |
| GG0110E | Orthotics/Prosthetics |
| GG0110Z | None of the above |
| GG0115A | ROM limitation: upper extremity |
| GG0115B | ROM limitation: lower extremity |
| GG0120A | Mobility devices: cane/crutch |
| GG0120B | Mobility devices: walker |
| GG0120C | Mobility devices: wheelchair (manual or electric) |
| GG0120D | Mobility devices: limb prosthesis |
| GG0120Z | Mobility devices: none of the above |
| GG0130A1 | Eating (Admission Performance) |
| GG0130A3 | Eating (Discharge Performance) |
| GG0130A5 | Eating (OBRA/Interim Performance) |
| GG0130B1 | Oral Hygiene (Admission Performance) |
| GG0130B3 | Oral Hygiene (Discharge Performance) |
| GG0130B5 | Oral Hygiene (OBRA/Interim Performance) |
| GG0130C1 | Toileting Hygiene (Admission Performance) |
| GG0130C3 | Toileting Hygiene (Discharge Performance) |
| GG0130C5 | Toileting Hygiene (OBRA/Interim Performance) |
| GG0130E1 | Shower/bathe self (Admission Performance) |
| GG0130E3 | Shower/bathe self (Discharge Performance) |
| GG0130E5 | Shower/bathe self (OBRA/Interim Performance) |
| GG0130F1 | Upper body dressing (Admission Performance) |
| GG0130F3 | Upper body dressing (Discharge Performance) |
| GG0130F5 | Upper body dressing (OBRA/Interim Performance) |
| GG0130G1 | Lower body dressing (Admission Performance) |
| GG0130G3 | Lower body dressing (Discharge Performance) |
| GG0130G5 | Lower body dressing (OBRA/Interim Performance) |
| GG0130H1 | Putting on/taking off footwear (Admission Performance) |
| GG0130H3 | Putting on/taking off footwear (Discharge Performance) |
| GG0130H5 | Putting on/taking off footwear(OBRA/Interim Performance) |
| GG0130I1 | Personal Hygiene (Admission Performance) |
| GG0130I3 | Personal Hygiene (Discharge Performance) |
| GG0130I5 | Personal Hygiene (OBRA/Interim Performance) |
| GG0170A1 | Roll left and right (Admission Performance) |
| GG0170A3 | Roll left and right (Discharge Performance) |
| GG0170A5 | Roll left and right (OBRA/Interim Performance) |
| GG0170B1 | Sit to lying (Admission Performance) |
| GG0170B3 | Sit to lying (Discharge Performance) |
| GG0170B5 | Sit to lying (OBRA/Interim Performance) |
| GG0170C1 | Lying to sitting on bed side (Admission Performance) |
| GG0170C3 | Lying to sitting on bed side (Discharge Performance) |
| GG0170C5 | Lying to sitting on bed side (OBRA/Interim Performance) |
| GG0170D1 | Sit to stand (Admission Performance) |
| GG0170D3 | Sit to stand (Discharge Performance) |
| GG0170D5 | Sit to stand (OBRA/Interim Performance) |
| GG0170E1 | Chair/bed-to-chair transfer (Admission Performance) |
| GG0170E3 | Chair/bed-to-chair transfer (Discharge Performance) |
| GG0170E5 | Chair/bed-to-chair transfer (OBRA/Interim Performance) |
| GG0170F1 | Toilet transfer (Admission Performance) |
| GG0170F3 | Toilet transfer (Discharge Performance) |
| GG0170F5 | Toilet transfer (OBRA/Interim Performance) |
| GG0170FF1 | Tub/Shower Transfer (Admission Performance) |
| GG0170FF3 | Tub/Shower Transfer (Discharge Performance) |
| GG0170FF5 | Tub/Shower Transfer (OBRA/Interim Performance) |
| GG0170G1 | Car Transfer (Admission Performance) |
| GG0170G3 | Car Transfer (Discharge Performance) |
| GG0170I1 | Walk 10 feet (Admission Performance) |
| GG0170I3 | Walk 10 feet (Discharge Performance) |
| GG0170I5 | Walk 10 feet (OBRA/Interim Performance) |
| GG0170J1 | Walk 50 feet with two turns (Admission Performance) |
| GG0170J3 | Walk 50 feet with two turns (Discharge Performance) |
| GG0170J5 | Walk 50 feet with two turns (OBRA/Interim Performance) |
| GG0170K1 | Walk 150 feet (Admission Performance) |
| GG0170K3 | Walk 150 feet (Discharge Performance) |
| GG0170K5 | Walk 150 feet (OBRA/Interim Performance) |
| GG0170L1 | Walking 10 feet on uneven surfaces (Admission Performance) |
| GG0170L3 | Walking 10 feet on uneven surfaces (Discharge Performance) |
| GG0170M1 | 1 step (curb) (Admission Performance) |
| GG0170M3 | 1 step (curb) (Discharge Performance) |
| GG0170N1 | 4 steps (Admission Performance) |
| GG0170N3 | 4 steps (Discharge Performance) |
| GG0170O1 | 12 steps (Admission Performance) |
| GG0170O3 | 12 steps (Discharge Performance) |
| GG0170P1 | Picking up object (Admission Performance) |
| GG0170P3 | Picking up object (Discharge Performance) |
| GG0170Q1 | Use of wheelchair/scooter (Admission Performance) |
| GG0170Q3 | Use of wheelchair/scooter (Discharge Performance) |
| GG0170Q5 | Use of wheelchair/scooter (OBRA/Interim Performance) |
| GG0170R1 | Wheel 50 feet with two turns (Admission Performance) |
| GG0170R3 | Wheel 50 feet with two turns (Discharge Performance) |
| GG0170R5 | Wheel 50 feet with two turns (OBRA/Interim Performance) |
| GG0170RR1 | Type wheelchair/scooter used (Admission Performance) |
| GG0170RR3 | Type wheelchair/scooter used (Discharge Performance) |
| GG0170RR5 | Type wheelchair/scooter used (OBRA/Interim Performance) |
| GG0170S1 | Wheel 150 feet (Admission Performance) |
| GG0170S3 | Wheel 150 feet (Discharge Performance) |
| GG0170S5 | Wheel 150 feet (OBRA/Interim Performance) |
| GG0170SS1 | Type wheelchair/scooter used (Admission Performance) |
| GG0170SS3 | Type wheelchair/scooter used (Discharge Performance) |
| GG0170SS5 | Type wheelchair/scooter used (OBRA/Interim Performance) |
| H0100A | Appliances: indwelling catheter |
| H0100B | Appliances: external catheter |
| H0100C | Appliances: ostomy |
| H0100D | Appliances: intermittent catheterization |
| H0100Z | Appliances: none of the above |
| H0200A | Urinary toileting program: has been attempted |
| H0200B | Urinary toileting program: response |
| H0200C | Urinary toileting program: current program/trial |
| H0300 | Urinary continence |
| H0400 | Bowel continence |
| H0500 | Bowel toileting program being used |
| H0600 | Constipation |
| I0020 | Indicate the resident’s primary medical condition category |
| I0020B | ICD Code 1 - 13 |
| I0100 | Cancer (with or without metastasis) |
| I0200 | Anemia |
| I0300 | Atrial fibrillation and other dysrhythmias |
| I0400 | Coronary artery disease (CAD) |
| I0500 | Deep venous thrombosis (DVT), PE, or PTE |
| I0600 | Heart failure |
| I0700 | Hypertension |
| I0800 | Orthostatic hypotension |
| I0900 | Peripheral vascular disease (PVD) or PAD |
| I1100 | Cirrhosis |
| I1200 | Gastroesophageal reflux disease (GERD) or ulcer |
| I1300 | Ulcerative colitis, Crohn's, inflammatory bowel disease |
| I1400 | Benign prostatic hyperplasia (BPH) |
| I1500 | Renal insufficiency, renal failure, ESRD |
| I1550 | Neurogenic bladder |
| I1650 | Obstructive uropathy |
| I1700 | Multidrug-resistant organism (MDRO) |
| I2000 | Pneumonia |
| I2100 | Septicemia |
| I2200 | Tuberculosis |
| I2300 | Urinary tract infection (UTI) (LAST 30 DAYS) |
| I2400 | Viral hepatitis (includes type A, B, C, D, and E) |
| I2500 | Wound infection (other than foot) |
| I2900 | Diabetes mellitus (DM) |
| I3100 | Hyponatremia |
| I3200 | Hyperkalemia |
| I3300 | Hyperlipidemia (e.g., hypercholesterolemia) |
| I3400 | Thyroid disorder |
| I3700 | Arthritis |
| I3800 | Osteoporosis |
| I3900 | Hip fracture |
| I4000 | Other fracture |
| I4200 | Alzheimer's disease |
| I4300 | Aphasia |
| I4400 | Cerebral palsy |
| I4500 | Cerebrovascular accident (CVA), TIA, or stroke |
| I4800 | Non-Alzheimer's Dementia |
| I4900 | Hemiplegia or hemiparesis |
| I5000 | Paraplegia |
| I5100 | Quadriplegia |
| I5200 | Multiple sclerosis |
| I5250 | Huntington's disease |
| I5300 | Parkinson's disease |
| I5350 | Tourette's syndrome |
| I5400 | Seizure disorder or epilepsy |
| I5500 | Traumatic brain injury (TBI) |
| I5600 | Malnutrition (protein, calorie), risk of malnutrition |
| I5700 | Anxiety disorder |
| I5800 | Depression (other than bipolar) |
| I5900 | Bipolar Disorder |
| I5950 | Psychotic disorder (other than schizophrenia) |
| I6000 | Schizophrenia |
| I6100 | Post-traumatic stress disorder (PTSD) |
| I6200 | Asthma, COPD, or chronic lung disease |
| I6300 | Respiratory failure |
| I6500 | Cataracts, glaucoma, or macular degeneration |
| I7900 | None of above active diagnoses within last 7 days |
| I8000A | Additional active ICD diagnosis 1 |
| I8000B | Additional active ICD diagnosis 2 |
| I8000C | Additional active ICD diagnosis 3 |
| I8000D | Additional active ICD diagnosis 4 |
| I8000E | Additional active ICD diagnosis 5 |
| I8000F | Additional active ICD diagnosis 6 |
| I8000G | Additional active ICD diagnosis 7 |
| I8000H | Additional active ICD diagnosis 8 |
| I8000I | Additional active ICD diagnosis 9 |
| I8000J | Additional active ICD diagnosis 10 |
| J0100A | Pain: received scheduled pain med regimen |
| J0100B | Pain: received PRN pain medications |
| J0100C | Pain: received non-medication intervention |
| J0200 | Should pain assessment interview be conducted |
| J0300 | Res pain interview: presence |
| J0410 | Res pain interview: frequency |
| J0510 | Pain Effect on Sleep |
| J0520 | Pain Interference with Therapy Activities |
| J0530 | Pain Interference with Day-to-Day Activities |
| J0600A | Res pain interview: intensity rating scale |
| J0600B | Res pain interview: verbal descriptor scale |
| J0700 | Should staff assessment for pain be conducted |
| J0800A | Staff pain assessment: non-verbal sounds |
| J0800B | Staff pain assessment: vocal complaints of pain |
| J0800C | Staff pain assessment: facial expressions |
| J0800D | Staff pain assessment: protective movements/postures |
| J0800Z | Staff pain assessment: none of these signs observed |
| J0850 | Staff pain assessment: frequency of pain |
| J1100A | Short breath/trouble breathing: with exertion |
| J1100B | Short breath/trouble breathing: sitting at rest |
| J1100C | Short breath/trouble breathing: lying flat |
| J1100Z | Short breath/trouble breathing: none of above |
| J1300 | Current tobacco use |
| J1400 | Prognosis: life expectancy of less than 6 months |
| J1550A | Problem conditions: fever |
| J1550B | Problem conditions: vomiting |
| J1550C | Problem conditions: dehydrated |
| J1550D | Problem conditions: internal bleeding |
| J1550Z | Problem conditions: none of the above |
| J1700A | Fall history: fall during month before admission |
| J1700B | Fall history: fall 2-6 months before admission |
| J1700C | Fall history: fracture from fall 6 month pre admit |
| J1800 | Falls since admit/prior assessment: any falls |
| J1900A | Falls since admit/prior assessment: no injury |
| J1900B | Falls since admit/prior assessment: injury (not major) |
| J1900C | Falls since admit/prior assessment: major injury |
| J2000 | Prior Surgery |
| J2100 | Recent Surgery Requiring Active SNF Care |
| J2300 | Knee Replacement - partial or total |
| J2310 | Hip Replacement - partial or total |
| J2320 | Ankle Replacement - partial or total |
| J2330 | Shoulder Replacement - partial or total |
| J2400 | Spinal surgery - spinal cord or major spinal nerves |
| J2410 | Spinal surgery - fusion of spinal bones |
| J2420 | Spinal surgery - lamina, discs, or facets |
| J2499 | Spinal surgery - other |
| J2500 | Ortho surgery - repair fractures of shoulder or arm |
| J2510 | Ortho surgery - repair fractures of pelvis, hip, leg, knee, or ankle |
| J2520 | Ortho surgery - repair but not replace joints |
| J2530 | Ortho surgery - repair other bones |
| J2599 | Ortho surgery - other |
| J2600 | Neuro surgery - brain, surrounding tissue or blood vessels |
| J2610 | Neuro surgery - peripheral and autonomic nervous system - open and percutaneous |
| J2620 | Neuro surgery - insertion or removal of spinal and brain neurostimulators, electrodes, catheters, and CSF drainage devices |
| J2699 | Neuro surgery - Other |
| J2700 | Cardiopulmonary surgery - heart or major blood vessels - open and percutaneous procedures |
| J2710 | Cardiopulmonary surgery - respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open and endoscopic |
| J2799 | Cardiopulmonary surgery - Other |
| J2800 | Genitourinary surgery - genital systems |
| J2810 | Genitourinary surgery - the kidneys, ureter, adrenals, and bladder—open, laparoscopic |
| J2899 | Other major genitourinary surgery |
| J2900 | Major surgery - tendons, ligament, or muscles |
| J2910 | Major surgery - the GI tract and abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, spleen—open or laparoscopic |
| J2920 | Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus—open |
| J2930 | Major surgery - the breast |
| J2940 | Major surgery - repair of deep ulcers, internal brachytherapy, bone marrow, or stem cell harvest or transplant |
| J5000 | Major surgery - Other surgery not listed above |
| K0100A | Swallow disorder: loss liquids/solids from mouth |
| K0100B | Swallow disorder: holds food in mouth/cheeks |
| K0100C | Swallow disorder: cough/choke with meals/meds |
| K0100D | Swallow disorder: difficulty or pain swallowing |
| K0100Z | Swallow disorder: none of the above |
| K0200A | Height (in inches) |
| K0200B | Weight (in pounds) |
| K0300 | Weight loss |
| K0310 | Weight gain |
| K0520A1 | Nutritional approaches: Parenteral/IV Feeding - Adm |
| K0520A2 | Nutritional approaches: Parenteral/IV Feeding - Not a Res |
| K0520A3 | Nutritional approaches: Parenteral/IV Feeding - While a Res |
| K0520A4 | Nutritional approaches: Parenteral/IV Feeding - At Discharge |
| K0520B1 | Nutritional approaches: Feeding Tube - Adm |
| K0520B2 | Nutritional approaches: Feeding Tube - Not a Res |
| K0520B3 | Nutritional approaches: Feeding Tube - While a Res |
| K0520B4 | Nutritional approaches: Feeding Tube - At Discharge |
| K0520C1 | Nutritional approaches: Mechanically Altered Diet - Adm |
| K0520C3 | Nutritional approaches: Mechanically Altered Diet - While a Res |
| K0520C4 | Nutritional approaches: Mechanically Altered Diet - At Discharge |
| K0520D1 | Nutritional approaches: Therapeutic Diet - Adm |
| K0520D3 | Nutritional approaches: Therapeutic Diet - While a Res |
| K0520D4 | Nutritional approaches: Therapeutic Diet - At Discharge |
| K0520Z1 | Nutritional approaches: None of the above - Adm |
| K0520Z2 | Nutritional approaches: None of the above - Not a Res |
| K0520Z3 | Nutritional approaches: None of the above - While a Res |
| K0520Z4 | Nutritional approaches: None of the above - At Discharge |
| K0710A2 | Prop calories parenteral/tube feed: while a resident |
| K0710A3 | Prop calories parenteral/tube feed: 7 days |
| K0710B2 | Avg fluid intake per day IV/ tube: while a resident |
| K0710B3 | Avg fluid intake per day IV/tube: 7 days |
| L0200A | Dental: broken or loosely fitting denture |
| L0200B | Dental: no natural teeth or tooth fragment(s) |
| L0200C | Dental: abnormal mouth tissue |
| L0200D | Dental: cavity or broken natural teeth |
| L0200E | Dental: inflamed/bleeding gums or loose teeth |
| L0200F | Dental: pain, discomfort, difficulty chewing |
| L0200G | Dental: unable to examine |
| L0200Z | Dental: none of the above |
| M0100A | Risk determination: has ulcer, scar, or dressing |
| M0100B | Risk determination: formal assessment |
| M0100C | Risk determination: clinical assessment |
| M0100Z | Risk determination: none of the above |
| M0150 | Is resident at risk of developing pressure ulcer |
| M0210 | Resident has Stage 1 or higher pressure ulcers |
| M0300A1 | Stage 1 pressure ulcers: number present |
| M0300B1 | Stage 2 pressure ulcers: number present |
| M0300B2 | Stage 2 pressure ulcers: number at admit/reentry |
| M0300C1 | Stage 3 pressure ulcers: number present |
| M0300C2 | Stage 3 pressure ulcers: number at admit/reentry |
| M0300D1 | Stage 4 pressure ulcers: number present |
| M0300D2 | Stage 4 pressure ulcers: number at admit/reentry |
| M0300E1 | Unstaged due to dressing: number present |
| M0300E2 | Unstaged due to dressing: number at admit/reentry |
| M0300F1 | Unstaged slough/eschar: number present |
| M0300F2 | Unstaged slough/eschar: number at admit/reentry |
| M0300G1 | Unstageable - deep tissue: number present |
| M0300G2 | Unstageable - deep tissue: number at admit/reentry |
| M1030 | Number of venous and arterial ulcers |
| M1040A | Other skin problems: infection of the foot |
| M1040B | Other skin problems: diabetic foot ulcer(s) |
| M1040C | Other skin problems: other open lesion(s) on the foot |
| M1040D | Other skin problems: lesions not ulcers, rashes, cuts |
| M1040E | Other skin problems: surgical wound(s) |
| M1040F | Other skin problems: burns (second or third degree) |
| M1040G | Skin tear(s) |
| M1040H | Moisture Associated Skin Damage (MASD) |
| M1040Z | Other skin problems: none of the above |
| M1200A | Skin/ulcer treatments: pressure reducing device for chair |
| M1200B | Skin/ulcer treatments: pressure reducing device for bed |
| M1200C | Skin/ulcer treatments: turning/repositioning |
| M1200D | Skin/ulcer treatments: nutrition/hydration |
| M1200E | Skin/ulcer treatments: pressure ulcer/injury care |
| M1200F | Skin/ulcer treatments: surgical wound care |
| M1200G | Skin/ulcer treatments: application of dressings |
| M1200H | Skin/ulcer treatments: apply ointments/medications |
| M1200I | Skin/ulcer treatments: apply dressings to feet |
| M1200Z | Skin/ulcer treatments: none of the above |
| N0300 | Number of days injectable medications received |
| N0350A | Insulin: insulin injections |
| N0350B | Insulin: orders for insulin |
| N0415A1 | High-Risk Drug Classes: Antipsychotic: Has received |
| N0415A2 | High-Risk Drug Classes: Antipsychotic: Indication noted |
| N0415B1 | High-Risk Drug Classes: Antianxiety: Has received |
| N0415B2 | High-Risk Drug Classes: Antianxiety: Indication noted |
| N0415C1 | High-Risk Drug Classes: Antidepressant: Has received |
| N0415C2 | High-Risk Drug Classes: Antidepressant: Indication noted |
| N0415D1 | High-Risk Drug Classes: Hypnotic: Has received |
| N0415D2 | High-Risk Drug Classes: Hypnotic: Indication noted |
| N0415E1 | High-Risk Drug Classes: Anticoagulant: Has received |
| N0415E2 | High-Risk Drug Classes: Anticoagulant: Indication noted |
| N0415F1 | High-Risk Drug Classes: Antibiotic: Has received |
| N0415F2 | High-Risk Drug Classes: Antibiotic: Indication noted |
| N0415G1 | High-Risk Drug Classes: Diuretic: Has received |
| N0415G2 | High-Risk Drug Classes: Diuretic: Indication noted |
| N0415H1 | High-Risk Drug Classes: Opioid: Has received |
| N0415H2 | High-Risk Drug Classes: Opioid: Indication noted |
| N0415I1 | High-Risk Drug Classes: Antiplatelet: Has received |
| N0415I2 | High-Risk Drug Classes: Antiplatelet: Indication noted |
| N0415J1 | High-Risk Drug Classes: Hypoglycemic: Has received |
| N0415J2 | High-Risk Drug Classes: Hypoglycemic: Indication noted |
| N0415K1 | High-Risk Drug Classes: Anti-convulsants: Has received |
| N0415K2 | High-Risk Drug Classes: Anti-convulsants: Indication noted |
| N0415Z1 | High-Risk Drug Classes: None of Above: Has Received |
| N0450A | Resident received antipsychotic medications |
| N0450B | GDR attempted |
| N0450C | Date of last attempted GDR |
| N0450D | Physician documented GDR |
| N0450E | Date physician documented GDR |
| N2001 | Drug Regimen Review |
| N2003 | Medication Follow-up |
| N2005 | Medication Intervention |
| O0110A1a | Treatment: Chemotherapy - On Adm |
| O0110A1b | Treatment: Chemotherapy - While a Res |
| O0110A1c | Treatment: Chemotherapy - At Discharge |
| O0110A2a | Treatment: Chemotherapy - IV - On Adm |
| O0110A2c | Treatment: Chemotherapy - IV - At Discharge |
| O0110A3a | Treatment: Chemotherapy - Oral - On Adm |
| O0110A3c | Treatment: Chemotherapy - Oral - At Discharge. |
| O0110A10a | Treatment: Chemotherapy - Other - On Adm |
| O0110A10c | Treatment: Chemotherapy - Other - At Discharge |
| O0110B1a | Treatment: Radiation - On Adm |
| O0110B1b | Treatment: Radiation - While a Resident |
| O0110B1c | Treatment: Radiation - At Discharge |
| O0110C1a | Treatment: Oxygen Therapy - On Adm |
| O0110C1b | Treatment: Oxygen Therapy - While a Res |
| O0110C1c | Treatment: Oxygen Therapy - At Discharge |
| O0110C2a | Treatment: Oxygen Therapy - Continuous - On Adm |
| O0110C2c | Treatment: Oxygen Therapy - Continuous - At Discharge |
| O0110C3a | Treatment: Oxygen Therapy - Intermittent - On Adm |
| O0110C3c | Treatment: Oxygen Therapy - Intermittent - At Discharge |
| O0110C4a | Treatment: Oxygen Therapy - High- concentration - On Adm |
| O0110C4c | Treatment: Oxygen Therapy - High- concentration - At Discharge |
| O0110D1a | Treatment: Suctioning - On Adm |
| O0110D1b | Treatment: Suctioning - While a Res |
| O0110D1c | Treatment: Suctioning - At Discharge |
| O0110D2a | Treatment: Suctioning - Scheduled - Adm |
| O0110D2c | Treatment: Suctioning - Scheduled - At Discharge |
| O0110D3a | Treatment: Suctioning - As Needed - Adm |
| O0110D3c | Treatment: Suctioning - As Needed - At Discharge |
| O0110E1a | Treatment: Tracheostomy care - Adm |
| O0110E1b | Treatment: Tracheostomy care - While a Resident |
| O0110E1c | Treatment: Tracheostomy care - At Discharge |
| O0110F1a | Treatment: Invasive Mechanical Ventilator - Adm |
| O0110F1b | Treatment: Invasive Mechanical Ventilator - While a Res |
| O0110F1c | Treatment: Invasive Mechanical Ventilator - At Discharge |
| O0110G1a | Treatment: Non-Invasive Mechanic Ventilator - On Adm |
| O0110G1b | Treatment: Non-Invasive Mechanic Ventilator - While a Res |
| O0110G1c | Treatment: Non-Invasive Mechanic Ventilator - At Discharge |
| O0110G2a | Treatment: Non-Invasive Mechanic Ventilator - BiPAP - On Adm |
| O0110G2c | Treatment: Non-Invasive Mechanic Ventilator - BiPAP - At Discharge |
| O0110G3a | Treatment: Non-Invasive Mechanic Ventilator - CPAP - On Adm |
| O0110G3c | Treatment: Non-Invasive Mechanic Ventilator - CPAP - At Discharge |
| O0110H1a | Treatment: IV Medications - On Adm |
| O0110H1b | Treatment: IV Medications - While a Res |
| O0110H1c | Treatment: IV Medications - At Discharge |
| O0110H2a | Treatment: IV Medications - Vasoactive Med - On Adm |
| O0110H2c | Treatment: IV Medications - Vasoactive Med - At Discharge |
| O0110H3a | Treatment: IV Medications - Antibiotics - On Adm |
| O0110H3c | Treatment: IV Medications - Antibiotics - At Discharge |
| O0110H4a | Treatment: IV Medications - Anticoagulant - On Adm |
| O0110H4c | Treatment: IV Medications - Anticoagulant - At Discharge |
| O0110H10a | Treatment: IV Medications - Other - On Adm |
| O0110H10c | Treatment: IV Medications - Other - At Discharge |
| O0110I1a | Treatment: Transfusions - On Adm |
| O0110I1b | Treatment: Transfusions - While a Res |
| O0110I1c | Treatment: Transfusions - At Discharge |
| O0110J1a | Treatment: Dialysis - On Adm |
| O0110J1b | Treatment: Dialysis - while a Resident |
| O0110J1c | Treatment: Dialysis - At Discharge |
| O0110J2a | Treatment: Dialysis - Hemodialysis - On Adm |
| O0110J2c | Treatment: Dialysis - Hemodialysis - At Discharge |
| O0110J3a | Treatment: Dialysis - Peritoneal - On Adm |
| O0110J3c | Treatment: Dialysis - Peritoneal - At Discharge |
| O0110K1b | Treatment: Hospice - While a Res |
| O0110M1b | Treatment: isolate/quarantine - While a Res |
| O0110O1a | Treatment: IV Access - On Adm |
| O0110O1b | Treatment: IV Access - While a Res |
| O0110O1c | Treatment: IV Access - At Discharge |
| O0110O2a | Treatment: IV Access - Peripheral - On Adm |
| O0110O2c | Treatment: IV Access - Peripheral - At Discharge |
| O0110O3a | Treatment: IV Access - Midline - On Adm |
| O0110O3c | Treatment: IV Access - Midline - At Discharge |
| O0110O4a | Treatment: IV Access - Central - On Adm |
| O0110O4c | Treatment: IV Access - Central - At Discharge |
| O0110Z1a | Treatment: None of the above - On Adm |
| O0110Z1b | Treatment: None of the above - While a Res |
| O0110Z1c | Treatment: None of the above - At Discharge |
| O0250A | Was influenza vaccine received |
| O0250B | Date influenza vaccine received |
| O0250C | If influenza vaccine not received, state reason |
| O0300A | Is pneumococcal vaccination up to date |
| O0300B | If pneumococcal vaccination not received, state reason |
| O0350 | Resident’s COVID-19 vaccination is up to date |
| O0400A1 | Speech-language/audiology: individual minutes |
| O0400A2 | Speech-language/audiology: concurrent minutes |
| O0400A3 | Speech-language/audiology: group minutes |
| O0400A3A | Speech-language/audiology: co-treatment minutes |
| O0400A4 | Speech-language/audiology: number of days |
| O0400A5 | Speech-language/audiology: start date |
| O0400A6 | Speech-language/audiology: end date |
| O0400B1 | Occupational therapy: individual minutes |
| O0400B2 | Occupational therapy: concurrent minutes |
| O0400B3 | Occupational therapy: group minutes |
| O0400B3A | Occupational therapy: co-treatment minutes |
| O0400B4 | Occupational therapy: number of days |
| O0400B5 | Occupational therapy: start date |
| O0400B6 | Occupational therapy: end date |
| O0400C1 | Physical therapy: individual minutes |
| O0400C2 | Physical therapy: concurrent minutes |
| O0400C3 | Physical therapy: group minutes |
| O0400C3A | Physical therapy: co-treatment minutes |
| O0400C4 | Physical therapy: number of days |
| O0400C5 | Physical therapy: start date |
| O0400C6 | Physical therapy: end date |
| O0400D1 | Respiratory therapy: number of minutes |
| O0400D2 | Respiratory therapy: number of days |
| O0400E1 | Psychological therapy: number of minutes |
| O0400E2 | Psychological therapy: number of days |
| O0400F1 | Recreational therapy: number of minutes |
| O0400F2 | Recreational therapy: number of days |
| O0420 | Distinct calendar days of therapy (7 look back) |
| O0425A1 | SLP and Audiology Services: Individual Minutes |
| O0425A2 | SLP and Audiology Services: Concurrent Minutes |
| O0425A3 | SLP and Audiology Services: Group Minutes |
| O0425A4 | SLP and Audiology Services: Co-treatment Minutes |
| O0425A5 | SLP and Audiology Services: Days |
| O0425B1 | Occupational Therapy: Individual Minutes |
| O0425B2 | Occupational Therapy: Concurrent Minutes |
| O0425B3 | Occupational Therapy: Group Minutes |
| O0425B4 | Occupational Therapy: Co-treatment Minutes |
| O0425B5 | Occupational Therapy: Days |
| O0425C1 | Physical Therapy: Individual Minutes |
| O0425C2 | Physical Therapy: Concurrent Minutes |
| O0425C3 | Physical Therapy: Group Minutes |
| O0425C4 | Physical Therapy: Co-treatment Minutes |
| O0425C5 | Physical Therapy: Days |
| O0430 | Distinct Calendar Days of Part A Therapy |
| O0500A | Range of motion (passive): number of days |
| O0500B | Range of motion (active): number of days |
| O0500C | Splint or brace assistance: number of days |
| O0500D | Bed mobility training: number of days |
| O0500E | Transfer training: number of days |
| O0500F | Walking training: number of days |
| O0500G | Dressing and/or grooming training: number of days |
| O0500H | Eating and/or swallowing training: number of days |
| O0500I | Amputation/prosthesis training: number of days |
| O0500J | Communication training: number of days |
| P0100A | Restraints used in bed: bed rail |
| P0100B | Restraints used in bed: trunk restraint |
| P0100C | Restraints used in bed: limb restraint |
| P0100D | Restraints used in bed: other |
| P0100E | Restraints in chair/out of bed: trunk restraint |
| P0100F | Restraints in chair/out of bed: limb restraint |
| P0100G | Restraints in chair/out of bed: chair stops rising |
| P0100H | Restraints in chair/out of bed: other |
| P0200A | Bed alarm |
| P0200B | Chair alarm |
| P0200C | Floor mat alarm |
| P0200D | Motion sensor alarm |
| P0200E | Wander/elopement alarm |
| P0200F | Other alarm |
| Q0110A | Asmt and Goal Participation: Resident |
| Q0110B | Asmt and Goal Participation: Family |
| Q0110C | Asmt and Goal Participation: Significant other |
| Q0110D | Asmt and Goal Participation: Legal guardian |
| Q0110E | Asmt and Goal Participation: Other legally authorized representative |
| Q0110Z | Asmt and Goal Participation: None of the above. |
| Q0310A | Resident's overall goal for discharge |
| Q0310B | Information source for Q0310A |
| Q0400A | Active discharge plan for return to community |
| Q0490 | Resident's preference to avoid being asked |
| Q0500B | Do you want to talk about returning to community |
| Q0500C | Information source for Q500B |
| Q0550A | Reasking resident preference |
| Q0550C | Information source for Q0550A |
| Q0610A | Referral been made to local contact agency |
| Q0620 | Reason Referral to Local Contact Agency Not Made |
| V0100A | Prior OBRA reason for assessment |
| V0100B | Prior PPS reason for assessment |
| V0100C | Prior assessment reference date |
| V0100D | Prior assessment BIMS summary score |
| V0100E | Prior assessment PHQ res: total mood severity score |
| V0100F | Prior assessment PHQ staff: total mood score |
| V0200A01A | CAA-Delirium: triggered |
| V0200A01B | CAA-Delirium: plan |
| V0200A02A | CAA-Cognitive loss/dementia: triggered |
| V0200A02B | CAA-Cognitive loss/dementia: plan |
| V0200A03A | CAA-Visual function: triggered |
| V0200A03B | CAA-Visual function: plan |
| V0200A04A | CAA-Communication: triggered |
| V0200A04B | CAA-Communication: plan |
| V0200A05A | CAA-ADL functional/rehab potential: triggered |
| V0200A05B | CAA-ADL functional/rehab potential: plan |
| V0200A06A | CAA-Urinary incontinence/indwelling catheter: triggered |
| V0200A06B | CAA-Urinary incontinence/indwelling catheter: plan |
| V0200A07A | CAA-Psychosocial well-being: triggered |
| V0200A07B | CAA-Psychosocial well-being: plan |
| V0200A08A | CAA-Mood state: triggered |
| V0200A08B | CAA-Mood state: plan |
| V0200A09A | CAA-Behavioral symptoms: triggered |
| V0200A09B | CAA-Behavioral symptoms: plan |
| V0200A10A | CAA-Activities: triggered |
| V0200A10B | CAA-Activities: plan |
| V0200A11A | CAA-Falls: triggered |
| V0200A11B | CAA-Falls: plan |
| V0200A12A | CAA-Nutritional status: triggered |
| V0200A12B | CAA-Nutritional status: plan |
| V0200A13A | CAA-Feeding tubes: triggered |
| V0200A13B | CAA-Feeding tubes: plan |
| V0200A14A | CAA-Dehydration/fluid maintenance: triggered |
| V0200A14B | CAA-Dehydration/fluid maintenance: plan |
| V0200A15A | CAA-Dental care: triggered |
| V0200A15B | CAA-Dental care: plan |
| V0200A16A | CAA-Pressure ulcer: triggered |
| V0200A16B | CAA-Pressure ulcer: plan |
| V0200A17A | CAA-Psychotropic drug use: triggered |
| V0200A17B | CAA-Psychotropic drug use: plan |
| V0200A18A | CAA-Physical restraints: triggered |
| V0200A18B | CAA-Physical restraints: plan |
| V0200A19A | CAA-Pain: triggered |
| V0200A19B | CAA-Pain: plan |
| V0200A20A | CAA-Return to community referral: triggered |
| V0200A20B | CAA-Return to community referral: plan |
| V0200B1 | CAA-Assessment process RN signature |
| V0200B2 | CAA-Assessment process signature date |
| V0200C1 | CAA-Care planning signature |
| V0200C2 | CAA-Care planning signature date |
| X0150 | Correction: type of provider |
| X0200A | Correction: resident first name |
| X0200C | Correction: resident last name |
| X0300 | Correction: resident gender |
| X0400 | Correction: resident birth date |
| X0500 | Correction: resident social security number |
| X0600A | Correction: OBRA reason for assessment |
| X0600B | Correction: PPS reason for assessment |
| X0600F | Correction: entry/discharge reporting |
| X0600H | Correction: SNF Part A PPS Discharge |
| X0700A | Correction: assessment reference date |
| X0700B | Correction: discharge date |
| X0700C | Correction: entry date |
| X0800 | Correction: correction number |
| X0900A | Correction: modification reasons - transcription error |
| X0900B | Correction: modification reasons - data entry error |
| X0900C | Correction: modification reasons - software error |
| X0900D | Correction: modification reasons - item coding error |
| X0900Z | Correction: modification reasons - other error |
| X1050A | Correction: inactivation reasons - event did not occur |
| X1050Z | Correction: inactivation reasons - other reason |
| X1100A | Correction: attestor first name |
| X1100B | Correction: attestor last name |
| X1100C | Correction: attestor title |
| X1100D | Correction: attestor signature |
| X1100E | Correction: attestation date |
| Z0100A | Medicare Part A: HIPPS code |
| Z0100B | Medicare Part A: Version code |
| Z0200A | State Medicaid Billing: Case Mix group |
| Z0200B | State Medicaid Billing: Version code |
| Z0250A | Alt State Medicaid Billing: Case Mix group |
| Z0250B | Alt State Medicaid Billing: Version Code |
| Z0300A | Insurance Billing: Billing Code |
| Z0300B | Insurance Billing: Billing Version |
| Z0400A | Attestation signature, title, sections, date |
| Z0400B | Attestation signature, title, sections, date |
| Z0400C | Attestation signature, title, sections, date |
| Z0400D | Attestation signature, title, sections, date |
| Z0400E | Attestation signature, title, sections, date |
| Z0400F | Attestation signature, title, sections, date |
| Z0400G | Attestation signature, title, sections, date |
| Z0400H | Attestation signature, title, sections, date |
| Z0400I | Attestation signature, title, sections, date |
| Z0400J | Attestation signature, title, sections, date |
| Z0400K | Attestation signature, title, sections, date |
| Z0400L | Attestation signature, title, sections, date |
| Z0500A | Signature of RN assessment coordinator |
| Z0500B | Date RN signed assessment as complete |
Section A Administrative Processing - Supporting Item (+)
Section A Administrative Processing - State Optional (s)
Section A Administrative Processing - Non-Submitted Item (-)
Section A Administrative Processing - Required Item (X)
Section B Administrative Processing - Supporting Item (+)
Section B Administrative Processing - State Optional (s)
Section B Administrative Processing - Non-Submitted Item (-)
Section B Administrative Processing - Required Item (X)
Section C Administrative Processing - Supporting Item (+)
Section C Administrative Processing - State Optional (s)
Section C Administrative Processing - Non-Submitted Item (-)
Section C Administrative Processing - Required Item (X)
Section A PDPM (Patient Driven Payment Model) - Supporting Item (+)
Section A PDPM (Patient Driven Payment Model) - State Optional (s)
Section A PDPM (Patient Driven Payment Model) - Non-Submitted Item (-)
Section A PDPM (Patient Driven Payment Model) - Required Item (X)
Section B PDPM (Patient Driven Payment Model) - Supporting Item (+)
Section B PDPM (Patient Driven Payment Model) - State Optional (s)
Section B PDPM (Patient Driven Payment Model) - Non-Submitted Item (-)
Section B PDPM (Patient Driven Payment Model) - Required Item (X)
