Updated research request forms and data security approval requirement effective 4/24/23
Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days: urinary incontinence.
The values available describing the primary diagnosis.
Primary Diagnosis Severity Rating (0-4) a.
Other diagnosis ICD b.
Other diagnosis ICD c.
Other diagnosis ICD d.
Other diagnosis ICD e.
Other diagnosis ICD f.
Other diagnosis severity rating (0-4) b.
Other diagnosis severity rating (0-4) c.
Other diagnosis severity rating (0-4) d.
Other diagnosis severity rating (0-4) e.
Other diagnosis severity rating (0-4) f.
The ICD-9 code indicating the first secondary payment reason.
The ICD-9 code indicating the primary payment reason.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0230 A. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 B. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 C. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 D. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 E. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 F. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 D. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 E. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis for PPS Payment if payment diagnosis is replaced 'V-Code' in M0240 F. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Optional field to capture the Case Mix Diagnosis. Effective August 2008.
Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into alimentary canal).
Intravenous or infusion therapy (excludes TPN).
None of the above therapies.
Parenteral nutrition (TPN or lipids).
Overall prognosis: best description of patient's overall prognosis for recoverey from this episode of illness.
Rehabiliatative prognosis: best desription of patient's prognosis for functional status.
Life expectancy (physician documentation is not required).
High risk factors characterizing this patient: alcoholism.
High risk factors characterizing this patient: drug dependency.
High risk factors characterizing this patient: heavy smoking.
High risk factors characterizing this patient: none of the above.
High risk factors characterizing this patient: obesity.
High risk factors characterizing this patient: unknown.
Current residence.
Structural barriers: narrow or obstructed doorways.
Structural barriers: none