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HIS Manual
Guidance Manual for Completion of
the Hospice Item Set (HIS)
Centers for Medicare and Medicaid
Services Hospice Quality Reporting
Program
V3.00 Effective February 16, 2021
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TABLE OF CONTENTS
TABLE OF CONTENTS ................................................................................................... i
CHAPTER 1: Background and Overview of the Hospice Item Set Manual .............. 1-1
1.1 Background and Statutory Authority............................................................. 1-1
1.2 Manual Overview ......................................................................................... 1-2
1.3 HIS Requirements and Reporting Years ...................................................... 1-2
1.4 Applicable Facilities and Requirements for New Facilities ........................... 1-5
1.5 Applicable Patients....................................................................................... 1-5
1.6 Record Types and Definitions ...................................................................... 1-5
1.7 Timing and Sequence Policies ..................................................................... 1-8
1.8 Maintenance of HIS Records ..................................................................... 1-12
1.9 Compliance with HQRP Requirements and APU Determinations .............. 1-12
CHAPTER 2: Item-Specific Instructions ................................................................... 2-1
2.1 Overview ...................................................................................................... 2-1
2.2 HIS Item Completion Conventions ............................................................... 2-2
Section A: Administrative Information ........................................................ 2A-1
Section F: Preferences ............................................................................... 2F-1
Section I: Active Diagnoses......................................................................... 2I-1
Section J: Health Conditions ...................................................................... 2J-1
Section N: Medications ............................................................................. 2N-1
Section Z: Record Administration ............................................................... 2Z-1
CHAPTER 3: Submission and Correction of Hospice Item Set Records.................. 3-1
3.1 Submitting HIS Records ............................................................................... 3-1
3.2 Timeliness Criteria ....................................................................................... 3-1
3.3 Validation of Records and Files.................................................................... 3-2
3.4 HIS Record Correction Policy....................................................................... 3-4
3.5 Correcting Errors in HIS Records That Have Not Yet Been Accepted
into the QIES ASAP System ........................................................................ 3-5
3.6 Correcting Errors in HIS Records That Have Been Accepted into the
QIES ASAP System ..................................................................................... 3-5
3.7 Special Manual Record Deletion Request .................................................... 3-9
List of Appendices
A: Acronyms And Glossary ..........................................................................................A-1
B: CMS Hospice Quality Reporting Program Resources..............................................B-1
C: Quality Measure Logical Specifications .................................................................. C-1
D(a): Hospice Item Set—Admission ........................................................................ D(a)-1
D(b): Hospice Item Set—Discharge ........................................................................ D(b)-1
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CHAPTER 1: BACKGROUND AND OVERVIEW OF THE HOSPICE ITEM SET
MANUAL
1.1
Background and Statutory Authority
Section 3004 of the Patient Protection and Affordable Care Act (ACA) authorizes the
Health and Human Services Secretary to establish a quality reporting program for
hospices. The ACA specifies that, for fiscal year (FY) 2014 and each subsequent FY,
hospice programs shall submit to the Secretary data on quality measures; the ACA also
describes measure endorsement requirements for any measures specified by the
Secretary. A hospice is not required to obtain patient consent to collect data for quality
measures for the Hospice Quality Reporting Program (HQRP) because the Centers for
Medicare & Medicaid Services (CMS) has the statutory authority to collect quality data
for hospices under Section 3004(c) of the ACA. CMS established the HQRP in the FY
2012 Hospice Wage Index final rule (76 FR 47318-47324). CMS finalized the
requirement for the Hospice Item Set (HIS) as part of the HQRP in the FY 2014 Hospice
Wage Index final rule (78 FR 48255-48262). Medicare-certified hospices (hospices) will
submit a HIS-Admission record and a HIS-Discharge record for each patient admission
on or after July 1, 2014. Hospices will continue to collect and submit HIS data on all
patient admissions; HIS data will be submitted to CMS on a regular and ongoing basis
from July 1, 2014, onward. As also required by the ACA, the Secretary is required to
establish procedures for making quality data submitted by hospices available to the
public. CMS will implement public reporting of quality data through the establishment of
a Care Compare website. Policies and procedures for Care Compare will be proposed
and finalized by CMS through rulemaking.
The HIS is a standardized set of items intended to capture patient-level data on each
hospice patient admission. Quality measures based on the HIS items are described in
the HQRP Quality Measures (QM) User’s Manual, available in the downloads section of
the HQRP Current Measures web page: https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/CurrentMeasures. Please note that the HIS is not an assessment instrument and does not
replace a thorough and ongoing assessment of each patient as required by the
Medicare Hospice Conditions of Participation, nor does it replace standard clinical
practice and judgment.
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1.2
Chapter 1: Introduction
Manual Overview
The purpose of the HIS Manual is to offer hospices guidance on the collection and
submission of HIS data to CMS. The manual is divided into three chapters and
appendices:
Chapter 1 – Provides an introduction of contextual information, timing and sequence
policies, and general guidance.
Chapter 2 – Contains item-specific guidance for completing each item in the HIS.
Chapter 3 – Includes information on HIS record submission and correction processes.
Appendices – Include the HIS-Admission and HIS-Discharge, glossary, and resources.
1.3
HIS Requirements and Reporting Years
Hospices shall submit two HIS records (a HIS-Admission record and a HIS-Discharge
record) for each patient admission occurring on or after July 1, 2014. HIS reporting
consists of three primary activities: HIS data collection, HIS record conversion, and HIS
record submission. See Figure 1.
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Chapter 1: Introduction
Figure 1: Three primary phases of HIS reporting
HIS Data Collection:
HIS Record Conversion:
Completing the HIS
items in conjunction
with the patient
assessment or by
abstracting data from
the clinical record
Converting HIS data
into the proper
electronic file format
(XML), either using a
vendor-designed
software or HART
(available at
www.qtso.com)
HIS Record Submission:
Zipping XML files into
the .zip format and
submitting to QIES
ASAP system
HIS data collection consists of selecting responses to HIS items in conjunction with patient
assessment activities or via abstraction from the patient’s clinical record. HIS data may be
collected on paper forms or using an electronic health record, but prior to submission, HIS
data must be converted into the proper electronic file format (XML), which is necessary for
successful submission. To convert HIS records into the proper XML file format, providers can
use either the Hospice Abstraction Reporting Tool (HART) software, which is free to
download and use (available at https://qtso.cms.gov/), or a vendor-designed software. Once
HIS records are converted, files are submitted to CMS via the Quality Improvement and
Evaluation System (QIES) Assessment Submission and Processing (ASAP) system.
Records should be completed and submitted according to the time frames outlined in
Section 1.7, Timing and Sequence Policies. Although this manual contains general HIS
record completion and submission policies, it does not contain detailed information about
conversion and submission software and procedures. Please see Chapter 3 for links to
additional resources on HIS record conversion and submission.
Any hospice that does not comply with the data submission requirements for any given
reporting year shall have its market basket update, also known as the Annual Payment
Update (APU), reduced by 2 percentage points for the relevant FY.
QIES to iQIES transition: No sooner than 2021, the QIES system will be transitioning to iQIES
(information available at https://qtso.cms.gov/. All references to QIES and ASAP in this
manual are valid until the iQIES system is effective.
HIS reporting activities currently operate on a cycle of HIS data collection and submission,
compliance determinations, and payment impact that spans 3 years. HQRP reporting years
are referenced by the relevant FY APU affected. For example, in Figure 2 below, the FY
2021 Reporting Year consists of data collection and submission in calendar year (CY) 2019,
compliance determinations in 2020, and payment impact for the FY 2021 APU.
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Chapter 1: Introduction
Figure 2: FY 2021 Reporting Year Activities
CY 2019
Data Collection and
Submission: Collect and
submit HIS data for all
patient admissions during
CY 2019 (January 1, 2019
– December 31, 2019).
CY 2020
Compliance
Determinations: In 2020,
CMS makes compliance
determinations based on
HIS submissions for
patient admissions
occurring in 2019.
CY 2021
Payment Impact:
Determinations of
noncompliance made in
2019 will go into effect in
FY 2021 (10/1/2020),
reducing the FY 2021 APU
by 2 percentage points.
To be compliant for the FY 2021 APU reporting year and all subsequent reporting
years, providers must submit at least 90% of their HIS records in accordance with the
30-day submission deadline specified in Section 1.7, Timing and Sequence Policies.
For more information on criteria for compliance determinations, see Section 1.9,
Compliance with HQRP Requirements and APU Determinations.
Due to COVID-19 and the resulting Public Health Emergency, the CY 2020 data used for
meeting the HQRP requirements will include July 1 through December 31, 2020 as Q1
and Q2 of 2020 (January 1-June 30, 2020) were exempted. This means that even if a
hospice submits HIS and CAHPS® Hospice Survey data for Q1 and Q2 2020, CMS will
not include any of that data for purposes of calculating whether a hospice meet HQRP
requirements impacting FY 2022 payments. Figure 2.1 outlines FY 2022 Reporting Year
Activities.
Figure 2.1: FY 2022 Reporting Year Activities
CY 2020
Data Collection and
Submission: Collect and
submit HIS data for all
patient admissions during
CY 2020 (July 1, 2020December 31, 2020)
*Q1 and Q2 of 2020
(January 1-June 30, 2020)
were exempted due to the
COVID-19 PHE
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CY 2021
Compliance
Determinations: In 2021,
CMS makes compliance
determinations based on
HIS submissions for
patient admissions
occurring in 2020
*Q3 and Q4 of 2020 (July
1-December 31, 2020)
since Q1 and Q2 were
exempted due to COVID19 PHE
CY 2022
Payment Impact:
Determinations of
noncompliance made in
2021 will go into effect in
FY 2022 (10/1/2021)
reducing the FY 2022
APU by 2 percentage
points.
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1.4
Chapter 1: Introduction
Applicable Facilities and Requirements for New Facilities
All Medicare-certified hospice providers are required to submit HIS data on all patient
admissions on or after July 1, 2014, onward.
Reporting eligibility and requirements for new hospice providers is addressed by CMS
through rulemaking.
For more details on requirements for new facilities, see proposed and final rules
published by CMS in the Federal Register: https://www.federalregister.gov/.
1.5
Applicable Patients
A HIS-Admission and a HIS-Discharge record are submitted for all patient admissions
to a Medicare-certified hospice program on or after July 1, 2014, regardless of the
following:
1.6
•
Payer source (Medicare, Medicaid, or private payer)
•
Patient age
•
Where the patient receives hospice services (home, nursing home,
assisted living facility, freestanding hospice)
•
Length of stay
Record Types and Definitions
Hospices are required to submit two HIS records for each patient admission to their
organization: a HIS-Admission record and a HIS-Discharge record. HIS-Admission
and HIS-Discharge completion is generally triggered by the patient’s admission to or
discharge from a Medicare-certified hospice.
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Admission: For the purposes of completing the HIS, a patient is considered admitted to
a hospice if the following conditions are met:
1. There is a signed election statement (or other agreement for care for nonMedicare patients).
2. The patient did not expire before the effective date of the election or agreement
for care.
3. The hospice made a visit in the setting where hospice services are to be initiated.
All three criteria listed above must be met for the patient to be considered admitted for
the purposes of HIS reporting (see Figure 3, below).
Figure 3: Flowchart for Patient Admission
Determining Whether an HIS-Admission Record is Required
Step 1: Is there a signed election statement (or
other agreement for care)?
NO
YES
YES
HIS NOT
REQUIRED
Step 2: Did patient expire prior to effective date?
NO
NO
Step 3: Was hospice visit made in the setting
where hospice services will be initiated?
YES
HIS
REQUIRED
Examples for patient admission:
Situation A: The patient signed an election statement on Monday with an effective
date of Tuesday. The nurse went to the patient’s home on Tuesday afternoon and the
patient expired before the nurse arrived, so the nurse completed a death visit.
Instructions: In this situation, the hospice is not required to submit an HISAdmission or HIS-Discharge. Although the patient signed the election statement
and survived to the effective date of the election, the patient expired before the
hospice visit could be made in the setting where the services were to be provided.
(continued)
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Examples for patient admission (continued):
Situation B: The consents were signed on the admission date, the nurse was in the
process of a visit where the care was to be provided, but the patient died during the
admission assessment.
Instructions: In this situation, the hospice is required to complete a HISAdmission and a HIS-Discharge record because the assessment had begun.
Situation C: The patient was being transported for admission to an inpatient facility.
The admission process (including the election of the benefit/hospice plan of care) was
scheduled for that afternoon. The patient expired prior to arriving at the inpatient
facility.
Instructions: In this situation, the hospice would not be required to complete HIS
records since the patient expired prior to the benefit/hospice plan of care election
and before a visit could be made where the services were going to be provided
(inpatient hospice).
Admission date: The date on which the hospice becomes responsible for the care of
the patient. For Medicare patients, this is the effective date of the election or re-election,
which may be the first day of hospice care or a later date, but may be no earlier than the
date of the election statement.
Discharge: For the purposes of completing the HIS, a patient is considered discharged
when the patient is no longer receiving services from the hospice or there is an
interruption in care/services related to one of the reasons listed in Item A2115 (expired,
revoked, no longer terminally ill, moved out of hospice service area, transferred to
another hospice, discharged for cause).
Discharge date: The date the hospice discharged the patient. If the patient expired, the
date of death is the discharge date. For live discharges, the date the patient revoked the
benefit or the date the hospice discharged the patient is the discharge date.
Special Circumstances
Certain circumstances may not be considered an admission or discharge for the
purposes of HIS completion. Special circumstances and the appropriate HIS record
action are presented below.
Patient transfers from a provider with one CCN to a provider with different CCN:
HIS reporting is at the CCN level. If a hospice patient’s care transfers or changes from
one hospice to another, and the two hospices have different CCNs, each hospice
should complete a HIS-Admission and a HIS-Discharge record for the care provided to
the patient by their organization. When the transferring hospice completes its HISDischarge, response 05, “transferred to another hospice,” should be selected for Item
A2115—Reason for Discharge.
Change in patient payer source or other administrative discharges with no
interruption in care: In some circumstances, a hospice’s policy may be to
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administratively discharge a patient and re-admit them. Such circumstances might
include the following:
•
Change in patient’s payer source: a private pay patient becomes eligible for
Medicare during the course of hospice stay; hospice completes an
“administrative” discharge and re-admission for the patient for billing purposes.
•
Hospice fails to meet the face-to-face requirement: if a hospice fails to meet the
face-to-face requirement, the hospice must administratively discharge the
patient, but the patient remains on service.
•
In general, as long as the patient remains under a hospice’s care with no
interruption in hospice service, completion of a HIS-Discharge is not required. In
both of the situations listed above, because the patient remained under the
hospice’s care with no interruption in service, the hospice would not be required
to submit a HIS-Discharge. Hospices should submit a HIS-Discharge once the
patient is no longer receiving hospice service or there is an interruption in care
related to one of the reasons for discharge listed in Item A2115.
Traveling patients: Hospice patients may on occasion travel outside of their “home
hospice’s” service area. In these circumstances, during the time the patient is outside of
the home hospice’s service area, the patient may receive services from a “host
hospice.” Per CMS regulations at 418.26, a hospice may discharge a patient if the
patient moves out of the service area or transfers to another hospice. However, per the
hospice regulations, a hospice may also enter into a written arrangement with another
Medicare-certified hospice program for the provision of core services to supplement
hospice employees/staff to meet the needs of patients. Circumstances under which a
hospice may enter into a written arrangement for the provision of core services include
a patient temporarily traveling outside of the hospice’s service area. In the case of a
traveling patient, whether or not a hospice should submit a HIS-Discharge and new HISAdmission depends on whether the home hospice discharged the patient and if the host
hospice admitted the patient to hospice care and filed a notice of election (NOE) within
the claims processing system. If there is no discharge by the home hospice, then the
home hospice is not required to submit a HIS-Discharge when the patient travels out of
the home hospice’s service area. Relatedly, the host hospice would not need to submit
a HIS-Admission or HIS-Discharge for a traveling patient whom they are providing
services to under a written agreement with the home hospice.
1.7
Timing and Sequence Policies
Hospices will submit two HIS records—a HIS-Admission record and a HIS-Discharge
record—for each patient admission. Hospices should complete and submit each
record in accordance with the policies listed in Table 2. Timing is not the same for all
HIS records, as timing is based on the Admission Date or Discharge Date.
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Table 2: Timing Definitions
Admission Date
(Item A0220)
The date on which the hospice becomes responsible for the care
of the patient. For Medicare patients, it is the same as the
effective date of the hospice benefit election (or re-election),
which may be the first day of hospice care or a later date, but
may be no earlier than the date of the election statement.1
Discharge Date
(Item A0270)
The date a patient leaves the hospice. If the patient has expired,
it is the date of death. For live discharges, it is the date the
patient revoked the hospice benefit or the hospice plan of care or
the date the hospice discharged the patient.2
Completion Date
(Item Z0500B)
The actual date on which the hospice completes the record.
Defined as the date all required information has been collected
and recorded, and staff have signed and dated that the record is
complete. This date should represent the completion date for the
HIS record that has been verified by the individual authorized to
do so. This individual signs and dates Item Z0500. The
completion date is recommended to be no later than the
completion deadline.
Completion
Deadline
The latest possible date on which a provider is encouraged to
complete a HIS record. The recommended completion deadline
for the HIS-Admission record is defined as the Admission Date +
14 calendar days. The recommended completion deadline for
the HIS-Discharge record is defined as the Discharge Date + 7
calendar days.
Submission Date
The submission date is defined as the date on which the
completed record was submitted and accepted by the QIES
ASAP system. The submission date should be no later than the
submission deadline.
Submission
Deadline
The submission deadline is defined as the latest possible date
on which the HIS record should be submitted and accepted by
the QIES ASAP system. The submission deadline for the HISAdmission record is defined as the Admission date + 30 calendar
days. The submission deadline for the HIS-Discharge record is
no later than the Discharge Date + 30 calendar days.
1
“Hospice Care.” 42 CFR 418.24 (2011).
2
Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual.
Completion Timing
For HIS-Admission records, the recommended Completion Deadline is defined as the
Admission Date + 14 calendar days. This means the Completion Date (Z0500B, the
actual date on which the record was completed) is recommended to be no later than the
Admission Date + 14 calendar days. The Completion Date can be equal to the
Admission Date or Completion Deadline.
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For HIS-Discharge records, the recommended Completion Deadline is defined as the
Discharge Date + 7 calendar days. This means the Completion Date (Z0500B, the
actual date on which the record was completed) is recommended to be no later than the
Discharge Date + 7 calendar days. The Completion Date can be equal to the Discharge
Date or Completion Deadline.
The completion deadlines above are outlined as CMS guidance only. Compliance with
completion deadlines is not considered in APU determinations. Although it is at the
discretion of the hospice to develop internal policies for completing HIS records, CMS
continues to recommend that providers complete and attempt to submit HIS records
early, prior to the submission deadline of 30 days, allowing ample time to address any
technical issues encountered in the QIES ASAP submission process, such as correcting
fatal error messages. If a hospice chooses to complete a HIS-Admission record prior to
the recommended Completion Deadline, the hospice should consider care processes
that were documented in the clinical record up to the Completion Date. If the patient’s
status with respect to care process items changes between the Completion Date and
the recommended Completion Deadline, hospices should not update the HIS-Admission
record. For additional information on timeliness criteria, see Chapter 3.
Completion timing policies above do not outline timing of care processes that are
captured by HIS items for quality measure calculation purposes. For more information
on timing for quality measure calculation purposes, please see the HQRP QM User’s
Manual, available on the “Current Measures” portion of the CMS HQRP website:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Current-Measures.html.
Submission Timing
For HIS-Admission records, the submission deadline is defined as the Admission Date +
30 calendar days. This means the Submission Date should be no later than the
Admission Date + 30 calendar days. The Submission Date can be equal to the
Admission Date, but no greater than 30 days later. The QIES ASAP system will issue a
warning on the Final Validation Report if the Submission Date is more than 30 days
after the Admission Date.
For HIS-Discharge records, the submission deadline is defined as the Discharge Date +
30 calendar days. This means the Submission Date should be no later than the
Discharge Date + 30 calendar days. The Submission Date can be equal to the
Discharge Date, but no greater than 30 days later. The QIES ASAP system will issue a
warning on the Final Validation Report if the Submission Date is more than 30 days
after the Discharge Date.
The submission deadlines timing policies outlined above only define the latest possible
date a hospice should submit each HIS record. For additional information on timeliness
criteria, see Chapter 3. For additional information on the impact of timely submission on
the APU determination, see Section 1.9.
Completion and submission timing is further illustrated in the tables below. The first
example in Tables 3 and 4 shows a HIS record that is completed and submitted on the
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latest possible date. The second example in each table shows a HIS record that is
completed and submitted early.
Table 3: Timing for HIS-Admission
Admission Date
(A0220)
Examples
Completed and
submitted by latest
dates
11/11/2020
Completed and
submitted early
11/11/2020
Completion Date
(Z0500B)
11/25/2020
(Admission
Date+14)
11/17/2020
Submission Date
12/11/2020
(Admission
Date+30)
11/20/2020
Table 4: Timing for HIS-Discharge
Discharge Date
(A0270)
Examples
Completion Date
(Z0500B)
Submission Date
Completed and
submitted by latest
dates
12/22/2020
12/29/2020
(Discharge
Date+7)
1/21/2021
(Discharge
Date+30)
Completed and
submitted early
12/22/2020
12/25/2020
1/3/2021
Hospices should have a system in place to ensure all required item sets are submitted
appropriately. If a hospice finds it has not submitted a required item set, the hospice
should submit the missing item set as soon as the error is identified.
If a hospice realizes that it will not meet the timeliness criteria (submission deadline) for
any given record, it should still complete and submit that record, even if that means the
record would be late. Late submission of HIS records will result in a non-fatal (warning)
error. Records containing non-fatal errors can still be accepted by the QIES ASAP
system.
Correction policies are further outlined in Chapter 3 of this manual.
Submission Sequence
The QIES ASAP system will issue a warning on the Final Validation Report when a
record is submitted out of sequence. Examples include the following:
•
A HIS-Admission record submitted after a HIS-Discharge record.
•
Submission of a HIS-Admission record where the prior record submitted was also
a HIS-Admission record.
•
Any record submitted on a patient after the submission of a HIS-Discharge
record indicating that the patient has expired (A2115 = 01).
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HIS-Admission and HIS-Discharge records may be completed and submitted on the
same day when situations arise that warrant this; for example, when a patient is
admitted and discharged on the same day.
1.8
Maintenance of HIS Records
We recommend that hospices retain a copy of HIS records, along with any corrected
versions. Note that although the signature page is not transmitted to the QIES ASAP
system, we recommend that it be retained by the hospice for potential future validation
purposes. Copies of HIS records can be maintained in electronic format.
Hospices must ensure that proper security measures are implemented via facility policy
to ensure the privacy and integrity of the HIS, regardless of whether the record is in
electronic or other form.
1.9
Compliance with HQRP Requirements and APU Determinations
The HQRP is currently a “pay–for-reporting” program, meaning that the act of submitting
required HIS records determines compliance with program requirements. The
performance rate on a specific quality measure is not a factor in determining compliance
with HQRP requirements at this time. Providers who do not comply with reporting
requirements for any given reporting period will have their APU reduced by 2
percentage points for the corresponding FY’s APU (see Section 1.3, HIS Requirements
and Reporting Years).
Specific criteria for determining compliance with HQRP requirements is proposed and
finalized through the federal rulemaking cycle. Timely submission of HIS records is now
a factor in determining a hospice’s compliance with HQRP requirements and APU
determinations. For more details on APU determination criteria, providers can view
proposed and final rules in the Federal Register: http://www.federalregister.gov.
Beginning with the FY 2017 reporting year, the Consumer Assessment of Healthcare
Providers and Systems (CAHPS) Hospice Survey became a part of general HQRP
requirements. This means that hospices will have to meet HIS and CAHPS
requirements in order to avoid the 2 percentage-point reduction in their APU. For more
information on CAHPS Hospice Survey requirements, please visit
http://www.hospicecahpssurvey.org.
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CHAPTER 2: ITEM-SPECIFIC INSTRUCTIONS
2.1
Overview
This chapter presents each item in the Hospice Item Set (HIS), along with instructions
for completing each item. Chapter 2 is organized to correspond with each section of the
HIS:
•
Section A: Administrative Information
•
Section F: Preferences
•
Section I: Active Diagnoses
•
Section J: Health Conditions (Pain and
Dyspnea)
•
Section N: Medications
•
Section Z: Record Administration
The beginning of each section contains an overview of all HIS items in the section, as
well as a section rationale, which explains the purpose of items in each section.
For each HIS item, the general order of information presented in Chapter 2 is as
follows:
•
Item Display: Provides a screenshot of each item as it appears on the HIS.
•
Item-Specific Instructions: Outlines the proper method for completing each HIS
item, including explanations of all response options for each item.
•
Item-Specific Tips:1 States clarifications, issues of note, and conditions to be
considered when completing HIS items.
•
Examples: 1 Illustrates examples of appropriate HIS item completion based on
sample clinical record documentation. This manual provides examples to assist
hospices in understanding the rationale for how to select the most accurate
responses when completing the HIS. These examples are not intended to dictate
or endorse language hospices may use in clinical record documentation. Direct
quotes that appear in examples are for illustration purposes only and do not
represent Centers for Medicare & Medicaid Services (CMS) endorsement of
specific documentation language or products.
1 Not all HIS items in Chapter 2 include item-specific tips and examples. Item display and item-specific
instructions are included for all HIS items.
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2.2
Chapter 2: Item-Specific Instructions
HIS Item Completion Conventions
General Conventions for Completing the HIS
1. A HIS (HIS-Admission and HIS-Discharge) should be fully and accurately completed
on all patient admissions on or after July 1, 2014.
2. To complete each HIS accurately and fully, hospice staff should understand what
information and data each item requires, and complete the item based only on what
is being requested. Responses to items on the HIS can be selected by the
assessing clinician as part of the patient visit/assessment, or can be based on
information documented in the clinical record and abstracted on or before the
Completion Date (Item Z0500B).
3. All completed HIS records must be electronically submitted to the Quality
Improvement and Evaluation System (QIES) Assessment Submission and
Processing (ASAP) system.
4. HIS record submission should follow the sequence outlined in Section 1.7, Timing
and Sequence Policies.
5. Policies outlined in Chapter 3 describe how to correct errors in a HIS record that has
already been accepted by the QIES ASAP system.
6. A HIS-Admission and HIS-Discharge should be submitted even if the patient revokes
the hospice benefit or is discharged from hospice before all HIS-related care
processes are complete. Follow the gateway questions and skip patterns for item
completion.
7. If a patient is discharged (for whatever reason) before a HIS-related care process
takes place, hospices should answer “no” to the gateway question and follow the
skip patterns as indicated on the HIS. Hospices should not leave any items blank
unless directed to do so by skip patterns.
Who May Complete the HIS
The HIS may be completed by any hospice staff member, including volunteers,
contractors, and affiliates (for example, staff from the quality division of the health
system to which a hospice belongs). The hospice is responsible for the accuracy and
completeness of information in the HIS. It is at the discretion of the hospice to determine
who can accurately complete the HIS. Each person completing any portion of a HIS
record should provide a signature in Section Z, Record Administration, in accordance
with the instructions provided in Section Z of this chapter.
Acceptable Sources of Documentation
The primary sources of information for completing the HIS include the following:
•
Data collected through clinical care processes as they are completed.
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HIS Manual
•
Chapter 2: Item-Specific Instructions
Documentation in the hospice clinical record from which the HIS responses can
be abstracted.
This means that, in general, sources external to the clinical record should not be used
when completing the HIS.
•
In some instances, a provider may consult sources other than the hospice clinical
record to complete HIS items. For example, completion of Section A
(Administrative Information) items may require review of claims or billing records;
Section F (Preferences) items may require review of POLST (Physician Order for
Life-Sustaining Treatment) forms or other equivalent forms.
•
If a particular HIS care process is not documented in the hospice clinical record,
the care process is considered not to have occurred. Complete the HIS items
accordingly, following skip patterns outlined in the HIS.
Relationship Between Care Processes and the HIS
Most of the items in the HIS-Admission relate to care processes that align with the initial
assessment or the comprehensive assessment period, as required by the Medicare
Hospice Conditions of Participation. Thus, completing the HIS-Admission record after
the comprehensive assessment period ends and before the completion deadline
(recommended as the Admission Date + 14 calendar days) meets the intent of the HIS.
Completion timelines outlined above may not necessarily align with timing requirements
for quality measure calculation purposes. See the HQRP QM User’s Manual, available
on the “Current Measures” portion of the CMS HQRP website:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Current-Measures.html for additional information
on how timing of items in the HIS relates to quality measure calculation. See Section
1.7 for additional information on timing and sequence policies.
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Chapter 2: Section A
SECTION A: ADMINISTRATIVE INFORMATION
Items in this section of the Hospice Item Set (HIS) pertain to administrative
information.
SECTION A: RATIONALE
This section obtains key information that uniquely identifies each patient, the hospice
from which he or she receives services, and the reason for record.
A0050: Type of Record
1. Add new record
Enter Code
2. Modify existing record
3. Inactivate existing record
Item-Specific Instructions
Indicate whether a HIS record is a new record to be added to the Quality
Improvement Evaluation System (QIES) Assessment Submission and Processing
(ASAP) system or if a HIS record that was previously submitted and accepted in the
QIES ASAP system requires modification or inactivation.
• Response 1, Add new record: Select response 1 if this is a new HIS record
that has not been previously submitted and accepted in the QIES ASAP
system.
– If there is an existing record for the same patient in the same hospice with
the same reason for record and with the same event date(s) (for example,
admission date or discharge date), then the current record would be a
duplicate and not a new record. In this case, when submitted, the record
will be rejected by the QIES ASAP system and a fatal error will be
reported to the provider on the Final Validation Report. Further details on
the Final Validation Report can be found in Chapter 3.
• Response 2, Modify existing record: Select response 2 if this is a request
to modify data for a record that already has been submitted and accepted in
the QIES ASAP system. Selecting response 2 creates a Modification
Request, which is used when a HIS record has been previously submitted
and accepted in the QIES ASAP system, but the record contains clinical or
non-key demographic errors.
– Errors in most items on a HIS record can be corrected with a Modification
Request, with some exceptions. For more details on Modification
Requests, see Chapter 3 of this manual.
• Response 3, Inactivate existing record: Select response 3 if this is a
request to inactivate a HIS record that has already been submitted and
accepted in the QIES ASAP system. Selecting response 3 creates an
Inactivation Request, which is used when a HIS record has been previously
submitted and accepted in the QIES ASAP system but one of the following
occurs:
– Particular item values (for example, recent event identifiers or key patient
identifiers) are inaccurate.
– The corresponding event did not occur (for example, a HIS discharge
record was submitted, but the patient was not discharged).
For more details on Inactivation Requests, see Chapter 3 of this manual.
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Chapter 2: Section A
Item-Specific Tips
Corrections should be made to any HIS record(s) that have errors to ensure that
the information in the QIES ASAP system accurately reflects any of the following:
the patient’s identification, location, and reason for the record.
A0100: Facility Provider Numbers. Enter code in boxes provided.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
Item-Specific Instructions
A0100: Facility Provider Numbers
A. National Provider Identifier (NPI):
• Enter the NPI. The NPI is a unique federal number that identifies providers
of health care services.
B. CMS Certification Number (CCN):
• Enter the hospice’s CCN. The CCN is also known as the Medicare
provider number. It is a six-digit number, usually in the format xx-xxxx.
A0205. Site of Service at Admission
Enter Code
01. Hospice in patient's home/residence
02. Hospice in Assisted Living facility
03. Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled
Nursing Facility (NF)
04. Hospice provided in a Skilled Nursing Facility (SNF)
05. Hospice provided in Inpatient Hospital
06. Hospice provided in Inpatient Hospice Facility
07. Hospice provided in Long Term Care Hospital (LTCH)
08. Hospice in Inpatient Psychiatric Facility
09. Hospice provided in a place not otherwise specified (NOS)
10. Hospice home care provided in a hospice facility
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Chapter 2: Section A
Item-Specific Instructions
A0205. Site of Service at Admission
• Response 01, Hospice in patient's home/residence: Select response 01 if the
patient received hospice care in their home/residence at the time of admission.
– This would include a patient receiving hospice care in the private
home/residence of a family member or caregiver.
• Response 02, Hospice in Assisted Living facility: Select response 02 if the
patient received hospice care in an Assisted Living facility at the time of
admission.
• Response 03, Hospice provided in Nursing Long-Term Care (LTC) or NonSkilled Nursing Facility (NF): Select response 03 if the patient received
hospice care in a Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility
(NF) at the time of admission.
• Response 04, Hospice provided in a Skilled Nursing Facility (SNF): Select
response 04 if the patient received hospice care in a Skilled Nursing Facility
(SNF) at the time of admission.
• Response 05, Hospice provided in Inpatient Hospital: Select response 05 if
the patient received hospice care in an Inpatient Hospital at the time of
admission.
• Response 06, Hospice provided in Inpatient Hospice Facility: Select
response 06 if the patient received hospice care in an Inpatient Hospice Facility
at the time of admission.
• Response 07, Hospice provided in Long Term Care Hospital (LTCH): Select
response 07 if the patient received hospice care in a Long Term Care Hospital
(LTCH) at the time of admission.
• Response 08, Hospice in Inpatient Psychiatric Facility: Select response 08 if
the patient received hospice care in an Inpatient Psychiatric Facility at the time
of admission.
• Response 09, Hospice provided in a place not otherwise specified (NOS):
Select response 09 if the patient received hospice care in a place not otherwise
specified (NOS) at the time of admission.
• Response 10, Hospice home care provided in a hospice facility: Select
response 10 if the patient received hospice care provided in a hospice residence
or facility at the time of admission.
Item-Specific Tips
• Response options for Item A0205 are structured to match sites of service found
on Medicare claims. Because the site of service must be identified on Medicare
claims for the initial level of care billed, identifying site of service the same way
when completing this HIS item can reduce administrative burden for the hospice.
• For purposes of completing Item A0205, SNF is not synonymous with nursing
facility. The response option for SNF is to be used for patients in a SNF or
patients in the SNF portion of a dually-certified nursing facility. If a beneficiary is
in a nursing facility but doesn't meet the criteria above, do not use the response
option for SNF; instead, use the response option for long-term care facility (also
known as NF or nursing facility).
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Chapter 2: Section A
A0220. Admission Date
Item-Specific Instructions
A0220. Admission Date
• Enter the date of admission to this hospice. Use the format Month-Day-Year:
MM-DD-YYYY. Do not leave any spaces blank. If the month and/or day contain
only a single digit, enter “0” in the first box of the month and/or day. For example,
November 1, 2018 would be entered as 11-01-2018. A day begins at 12:00 a.m.
and ends at 11:59 p.m.
• The admission date specifies the date on which the hospice becomes responsible
for the care of the patient.
– For Medicare patients, this is the effective date of election or of re-election.
– For patient transfers (regardless of payer source), this is the date the patient
was transferred to your hospice from another hospice organization;
specifically, the date your hospice became responsible for the patient’s
hospice care.
A0245. Date Initial Nursing Assessment Initiated
Item-Specific Instructions
For more information on what constitutes a patient admission for the purposes of HIS
reporting, see Section 1.6, Record Types and Definitions.
A0245. Date Initial Nursing Assessment Initiated
• Enter the date the hospice clinician began the initial nursing assessment.
Use the format Month-Day-Year: MM-DD-YYYY. Do not leave any spaces
blank. If the month and/or day contain only a single digit, enter “0” in the first
box of the month and/or day. For example, November 1, 2021 would be
entered as 11-01-2021.
• Item A0245 refers to the initial assessment the registered nurse must complete,
as defined in the Medicare Hospice Conditions of Participation.
• Item A0245 is intended to reflect the date on which the initial nursing assessment
(as defined in the Medicare Hospice Conditions of Participation) was initiated. For
patients that are discharged for any reason before the initial assessment is
completed, enter the date on which the initial assessment was initiated, even if
the entire initial assessment was not completed or was initiated in another care
setting. If no initial assessment was initiated, enter a dash (-) for Item A0245.
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Chapter 2: Section A
A0250. Reason for Record
Enter Code
01. Admission
09. Discharge
Item-Specific Instructions
A0250. Reason for Record
• Response 01, Admission: Select response 01 for a HIS-Admission record.
• Response 09, Discharge: Select response 09 for a HIS-Discharge record.
Item-Specific Tips
A HIS-Admission and a HIS-Discharge record must be completed for each patient
admission. For detailed information on the requirements for sequencing the
completion and submission of the two record types, see Chapter 1 of this manual.
A0270. Discharge Date
Item-Specific Instructions
Complete only if A0250 = 09, Discharge. For more information on what constitutes
a patient discharge for the purposes of HIS reporting, see Section 1.6, Record
Types and Definitions.
• Enter the date the patient was discharged from hospice (whether or not
return is anticipated). Use the format Month-Day-Year: MM-DD-YYYY. Do
not leave any spaces blank. If the month and/or day contain only a single
digit, enter “0” in the first box of the month and/or day. For example,
November 1, 2021 would be entered as 11-01-2021.
• If the patient expired, the date of death is the discharge date.
• For live discharges, the date the patient revoked the hospice benefit or the
date the hospice discharged the patient is the discharge date.
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Chapter 2: Section A
A0500. Legal Name of Patient
A. First name:
B. Middle initial:
C. Last name:
D. Suffix:
Item-Specific Instructions
A0500. Legal Name of Patient
The legal name is the patient’s name as it appears on the Medicare card. If the
patient is not enrolled in the Medicare program, use the patient’s name as it appears
on a Medicaid card or other government-issued document.
A. First name
• Enter the patient’s first name.
B. Middle initial
• Enter the patient’s middle initial. If the patient has no middle initial, leave the
item blank. If the patient has two or more middle names, use the initial of the
first middle name.
C. Last name
• Enter the patient’s last name. This field has a limit of 18 characters. The
hospice must be consistent when entering the patient’s last name because
errors in the patient’s name item may cause a new record to be created for the
same patient in the QIES ASAP system.
D. Suffix
• Enter the appropriate suffix (for example, Jr., Sr.), if any. If the patient has
no suffix, leave the item blank.
Item-Specific Tips
Be sure to carefully check the spelling of the patient’s name each time a HIS record is
submitted. Typographical errors in the patient’s name item may cause a new record
to be created for the same patient in the QIES ASAP system.
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Chapter 2: Section A
A0550. Patient ZIP Code. Enter code in boxes provided.
Patient ZIP Code:
-
Item-Specific Instructions
A0550. Patient ZIP Code
• Enter the ZIP Code for the address at which the patient is residing while
receiving hospice services, even if this is not the patient’s usual (or legal)
residence.
• If known, enter the “extended” ZIP Code (ZIP Code plus 4 digit code), starting
with the left-most box, followed by one digit per box. At a minimum, the five digit
ZIP Code must be entered. If entering the five digit ZIP Code only, start with the
left-most box, leaving the last four boxes blank.
• The patient’s ZIP Code is used for Care Compare to determine locations where
your hospice provided services.
Item-Specific Tips
The ZIP Code in A0550 should reflect the ZIP Code where the patient will reside while
receiving hospice services:
• In a situation where the hospice patient lives in a city other than the city where
they are receiving hospice services (e.g., hospice patient lives in City A , but is
currently receiving hospice care while staying at a daughter’s home in City B),
enter the ZIP Code for the location where the patient is receiving hospice services
(in this example, the ZIP Code for the daughter’s home in City B).
• In a situation where a patient is residing and receiving hospice services in a
facility other than their home (e.g., nursing facility, assisted living facility, inpatient
hospice facility), enter the ZIP Code of the facility where the hospice services are
provided, not the ZIP Code of the patient’s permanent home/billing address.
• In a situation where a patient is admitted to hospice and initially receives hospice
services in a GIP facility with plans to move to a home at a future point, enter the
ZIP Code for the GIP facility where the initial hospice services are being provided.
• In a situation where the first encounter between the hospice and patient is in a
facility other than where the patient will be receiving hospice services (e.g., the
hospice makes the initial visit in the hospital, pending patient’s discharge to
home), enter the ZIP Code of the address where the hospice services will be
provided (in this example, the ZIP Code of the patient’s home).
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Chapter 2: Section A
A0600. Social Security and Medicare Numbers
A. Social Security Number:
B. Medicare number (or comparable railroad insurance number):
Item-Specific Instructions
A0600. Social Security and Medicare Numbers
A. Social Security Number
•
Enter the Social Security Number (SSN), one number per space, starting with
the left-most space. If the patient does not have an SSN or the SSN is
unavailable, the item may be left blank.
- An SSN is a tracking number assigned to an individual by the U.S. federal
government for taxation, benefits, and identification purposes.
B. Medicare Number (or comparable railroad insurance number)
•
Enter the Medicare number exactly as it appears on the patient’s Medicare
card.
•
A Medicare number is an identifier assigned to an individual for participation in
national health insurance program(s). The Medicare number may contain both
letters and numbers.
- In an effort to fight identity theft for Medicare beneficiaries, CMS is replacing
the SSN-based Health Insurance Claim Number (HICN) with a new
Medicare Beneficiary Identifier (MBI).
- April 1, 2018 – December 31, 2019: Enter the patient’s HICN, identified as
the Medicare Claim Number on the patient’s Medicare card. The HICN may
differ from the patient’s SSN. For example, many patients receive Medicare
benefits based on a spouse’s Medicare eligibility, or the patient’s new MBI.
- After December 31, 2019: Enter the MBI. Do not report the patient’s SSNbased HICN.
•
If the patient does not have a Medicare number, a Railroad Retirement Board
(RRB) number may be substituted. RRB numbers contain both letters and
numbers; to enter the RRB number, enter the first letter of the code in the leftmost space followed by one letter/digit per space.
•
Confirm that the patient’s name on the HIS record matches the patient’s name on
the Medicare or RRB card.
•
If the patient has neither a Medicare number nor an RRB number, the item may
be left blank.
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Chapter 2: Section A
Item-Specific Tips
•
•
•
•
To avoid inaccuracies in patient record matching, Item A0600 should only be left
blank if the patient does not have a SSN or in rare instances where the SSN is
unavailable.
Item A0600B can only be a Medicare number or an RRB number.
The Medicare Number or RRB number entered in A0600B is not intended to
reflect the patient’s payer source. For the purposes of HIS item completion, the
Medicare Number or RRB number is used for patient identification purposes only.
If the patient has a Medicare Number or RRB number, enter it in A0600B, even if
Medicare is not a payer or is a secondary payer.
If the hospice is notified after the record has been submitted that the patient does
have a Medicare number, include it on the next record. For instance, if the
Medicare number is received after submission of the HIS-Admission record,
include the patient’s Medicare number on the HIS-Discharge record. Including the
Medicare number on the HIS-Discharge record at a later date does not require a
Modification Request to the original HIS-Admission Record.
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Chapter 2: Section A
A0700. Medicaid Number. Enter "+" if pending, "N" if not a Medicaid Recipient.
Item-Specific Instructions
A0700. Medicaid Number
•
Enter the Medicaid number if the patient is a Medicaid recipient. Enter one
number per box, beginning in the left-most box.
– Enter a “+” in the left-most box if the Medicaid number is pending.
– If the patient is not a Medicaid recipient, enter “N” in the left-most box.
– Confirm that the patient’s legal name on the HIS record matches the
patient’s legal name on the Medicaid card.
– If the patient refuses to supply his or her Medicaid number or the
Medicaid number is unknown, leave A0700 blank.
Item-Specific Tips
•
•
•
To obtain the Medicaid number, check the patient’s Medicaid card, admission or
transfer records, or hospice clinical record.
The Medicaid Number entered in A0700 is not intended to reflect the patient’s
payer source. For the purposes of HIS item completion, the Medicaid Number is
used for patient identification purposes only. If the patient has a Medicaid
Number, enter it in A0700, even if Medicaid is not a payer or is a secondary
payer.
If the hospice is notified after the record has been submitted that the patient
does have a Medicaid number, include it on the next record. For instance, if the
Medicaid number is received after submission of the HIS-Admission record,
include the patient’s Medicaid number on the HIS-Discharge record. Including
the Medicaid number on the HIS-Discharge record at a later date does not
require a Modification Request to the original HIS-Admission Record.
A0800. Gender
Enter Code
1. Male
2. Female
Item-Specific Instructions
A0800. Gender
• Response 1, Male: Select response 1 if patient is male.
• Response 2, Female: Select response 2 if patient is female.
A0900. Birth Date
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Chapter 2: Section A
Item-Specific Instructions
A0900. Birth Date
• Enter the birth date of the patient. Use the format Month-Day-Year: MM-DDYYYY. Do not leave any spaces blank. If the month and/or day contain only a
single digit, enter “0” in the first box of the month and/or day. For example,
November 1, 2021 would be entered as 11-01-2021.
• If only the birth year or the birth year and birth month of the patient are known,
handle each situation as follows:
– If only the birth year is known, enter the year in the “year” boxes of A0900
and leave the “month” and “day” boxes blank.
– If the birth year and birth month are known, but not the birth day, enter
the year in the “year” boxes of A0900, enter the month in the “month”
boxes, and leave the “day” boxes blank.
A1000. Race/Ethnicity
Check all that apply
A. American Indian or Alaska Native
B. Asian
C. Black or African American
D. Hispanic or Latino
E. Native Hawaiian or Other Pacific Islander
F. White
Item-Specific Instructions
A1000. Race/Ethnicity
•
Check the box(es) that correspond(s) to the race or ethnic
category/categories the patient uses to identify him or herself, or check the
box(es) the patient’s family, significant other, guardian, or legally authorized
representative uses to identify the patient. Observer identification can be used
to complete this item if the patient is unable to respond and/or no family
member, significant other, guardian, or legally authorized representative is
available.
Check all that apply.
•
Check A, American Indian or Alaska Native, if the patient is American Indian
or Alaska Native.
– A person having origins in any of the original peoples of North and South
America (including Central America) and who maintains tribal affiliation or
community attachment.
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Chapter 2: Section A
Item-Specific Instructions (continued)
•
Check B, Asian, if the patient is Asian.
– A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent, including, for example,
Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.
•
Check C, Black or African American, if the patient is Black or African American.
– A person having origins in any of the black racial groups of Africa. Terms
such as "Haitian" or "Negro" can be used in addition to "Black or African
American."
•
Check D, Hispanic or Latino, if the patient is Hispanic or Latino.
– A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race. The term "Spanish
origin" can be used in addition to "Hispanic or Latino."
•
Check E, Native Hawaiian or Other Pacific Islander, if the patient is Native
Hawaiian or other Pacific Islander.
– A person having origins in any of the original peoples of Hawaii, Guam,
Samoa, or other Pacific Islands.
•
Check F, White, if the patient is White.
– A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
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Chapter 2: Section A
A1400. Payor Information
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care)
G. Other government (e.g., TRICARE, VA, etc.)
H. Private Insurance/Medigap
I. Private managed care
J. Self-pay
K. No payor source
X. Unknown
Y. Other
Item-Specific Instructions
•
Check the box(es) that best correspond(s) to the patient’s current existing
payment sources. Check all that apply.
– This item is intended to identify all payors that the patient has, regardless of
whether or not the payor is expected or likely to provide reimbursement for
any services, supplies, medications, etc. that the patient may receive during
the hospice episode of care.
– Although Item A1400 is intended to reflect all current, existing payor
sources, pending payor sources should not be included in A1400 (i.e., do
not report payment source(s) which have been applied for but not yet
received).
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Chapter 2: Section A
Item-Specific Tips (continued)
•
•
•
Item A1400 is intended to reflect all current existing payor sources, even if the
payor is not expected or likely to provide reimbursement. For example, if a
Medicare beneficiary was a Medicare Advantage patient prior to electing the
hospice benefit, the hospice should still select “B. Medicare (managed care/Part
C/Medicare Advantage)” as one of the existing payment sources for A1400 even
though Medicare Advantage may not reimburse the hospice directly for any
services.
It is recommended that providers take efforts to validate existing pay sources (e.g.,
ask patients to present their Medicare card); however, for the purposes of
completing Item A1400, eligibility for or existence of pay sources can be based on
patient/caregiver report.
For the purposes of completing Item A1400, existence of pay sources can be
based on patient/caregiver report, and gathering additional supplementary
financial information is not likely to be necessary. It is possible to collect the
information during the referral/intake/admission process when verifying insurance
sources, or during preadmission/admission discussions of what the hospice
benefit will cover and what the patient may be responsible for. These
conversations may take place as part of an overall assessment of the patient’s
ability to pay for such items that may not traditionally be paid for by the Hospice
Benefit.
•
Response A, Medicare (traditional fee-for-service) should be selected if the
patient is a traditional fee-for-service Medicare patient. This includes if the patient
has Medicare Part D.
•
Response B, Medicare (managed care/Part C/Medicare Advantage) should be
selected if the patient has Medicare HMO/managed care, another Medicare
Advantage Plan, or Medicare Part C. If the patient was a Medicare Advantage
patient prior to enrolling in hospice, select response option B even though
Medicare Advantage may not reimburse the hospice directly for any services. If
the patient was Part C/Medicare Advantage prior to enrolling in hospice, select the
response options for BOTH part C and traditional fee-for-service, as applicable.
•
Response C, Medicaid (traditional fee-for-service) should be selected if the
patient has traditional fee-for-service Medicaid.
•
Response D, Medicaid (managed care) should be selected if the patient has
Medicaid managed care.
•
Response G, Other government (e.g., TRICARE, VA, etc.) should be selected if
the patient has a government plan besides Medicare and/or Medicaid. This would
include TRICARE, VA, etc.
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Chapter 2: Section A
Item-Specific Tips (continued)
•
Response H, Private Insurance/Medigap should be selected if the patient has
available any private insurance. This would include commercial plans irrespective
of how they were purchased (i.e., regardless of whether they are provided through
an employer or purchased individually by the patient or through a health insurance
exchange, etc.). This response option should also be used for prescription drug
coverage from a private insurer in addition to/other than Medicare Part D
coverage.
•
Response I, Private Managed Care should be selected if the patient has
available any private insurance that is a managed care plan. This would include
commercial or privately purchased managed care plans (e.g., commercial HMO or
PPO plans) irrespective of how they were purchased (i.e., regardless of whether
they are provided through an employer or purchased individually by the patient or
through a health insurance exchange, etc.).
Response J, Self-pay should be selected if the patient has any amount of
personal funds available to contribute to healthcare expenses (services, supplies,
medications, etc.) during the hospice episode of care. For purposes of completing
Item A1400, the minimum threshold for a “self-pay” patient would be ability to pay
for any low-cost medication, supply or service (e.g., medication co-pay or overthe-counter medication). Based on this definition of self-pay, for certain providers,
a large majority of patients may be identified as self-pay; this is acceptable. SelfPay should be chosen even if the patient is not actively paying for anything, but
could pay for something or has the funds if needed. Additionally, the intent of the
self-pay response option is not to assess patients’ ability to self-pay, but rather to
determine availability of funds to cover costs of care. Selecting the self-pay
response option obligates neither the hospice nor the patient to use those funds to
pay for care, should a need to self-pay arise. In this sense, collection of data to
complete Item A1400 should not influence the delivery of hospice services based
on the patient’s ability to self-pay for care, or based on availability of other pay
sources the patient may have.
Response K, No payor source should be selected if the patient does not have
any of the payor sources in response options A-I available, nor do they have any
personal funds available (response option J, Self-pay) to contribute to healthcare
expenses (services, supplies, medications, etc.) during the hospice episode of
care.
Response X, Unknown should be selected if the patient is not confirmed to have
any of the above payor sources in response options A-K available to contribute to
healthcare expenses (services, supplies, medications, etc.) during the hospice
episode of care.
Response Y, Other should be selected if the patient has available one or more
payor sources that is not listed in responses options A-K above to contribute to
healthcare expenses (services, supplies, medications, etc.) during the hospice
episode of care.
•
•
•
•
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Chapter 2: Section A
Item-Specific Tips (continued)
•
For charity patients: For the purposes of completing the HIS, there are two types
of charity care patients: patients that will receive funds from a funded charity care
program and patients that have available no other pay source and are not part of a
funded charity care program. Select response “Y, Other” if the patient has
available as a pay source a funded charity program. Select response “K, No payor
source” if a patient does not have available any of the pay sources listed in A-J,
nor will they be part of a funded charity program.
•
For classifying individual commercial plans, providers should use their best
judgement or follow-up with the appropriate commercial or private contact to
classify individual commercial plans. For state-specific plans (other than traditional
Medicaid) or other government plans (e.g., Tricare or other VA plans), providers
should follow-up with the appropriate state or government contacts for advice on
classifying these plans.
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Chapter 2: Section A
A1802. Admitted From. Immediately preceding this admission, where was the
patient?
Enter Code
01. Community residential setting (e.g., private home/apt., board/care,
assisted living, group home, adult foster care)
02. Long-term care facility
03. Skilled Nursing Facility (SNF)
04. Hospital emergency department
05. Short-stay acute hospital
06. Long-term care hospital (LTCH)
07. Inpatient rehabilitation facility or unit (IRF)
08. Psychiatric hospital or unit
09. ID/DD Facility
10. Hospice
99. None of the above
Item-Specific Instructions
Enter the two-digit response that best describes the setting in which the patient was
staying immediately preceding this admission.
•
Response 01, Community residential setting: Select response 01 if the
patient was admitted from a private home, apartment, board and care, assisted
living facility, group home, or adult foster care. A community residential setting is
defined as any house, condominium, or apartment in the community, whether
owned by the patient or another person, retirement communities, or
independent housing for the elderly.
•
Response 02, Long-term care facility (also known as a Non-Skilled
Nursing Facility or NF): Select response 02 if the patient was admitted from
an institution that is primarily engaged in providing medical and non-medical
care to people who have a chronic illness or disability. These facilities provide
care to people who cannot be cared for at home or in the community. Long-term
care facilities provide a wide range of personal care and health services for
individuals who cannot take care of themselves due to physical, emotional, or
mental health issues.
Response 03, Skilled Nursing Facility (SNF): Select response 03 if the
patient was admitted from a nursing facility with the staff and equipment for the
provision of skilled nursing services, skilled rehabilitative services, and/or other
related health services. This category includes swing bed hospitals, which are
generally small, rural hospitals or critical access hospitals (CAH) participating in
Medicare that have CMS approval to provide post-hospital SNF care and meet
certain requirements.
Response 04, Hospital emergency department: Select response 04 if the
patient was admitted from an organized hospital-based facility for the provision
of unscheduled or episodic services to patients who present for immediate
medical attention.
•
•
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Chapter 2: Section A
Item-Specific Instructions (continued)
•
•
•
•
•
•
•
Response 05, Short-stay acute hospital: Select response 05 if the patient was
admitted from a hospital that is contracted with Medicare to provide acute inpatient
care and accept a predetermined rate as payment in full.
Response 06, Long-term care hospital (LTCH): Select response 06 if the
patient was admitted from an acute-care hospital that provides treatment for
patients who stay, on average, more than 25 days. Most patients are transferred
from an intensive or critical care unit. Services provided include comprehensive
rehabilitation, respiratory therapy, head trauma treatment, and pain management.
Response 07, Inpatient rehabilitation facility or unit (IRF): Select response 07
if the patient was admitted from a hospital, or a distinct unit of a hospital, that
provides an intensive rehabilitation program to inpatients.
Response 08, Psychiatric hospital or unit: Select response 08 if the patient was
admitted from an institution that provides, by or under the supervision of a
physician, psychiatric services for the diagnosis and treatment of mentally ill
patients.
Response 09, ID/DD Facility: Select response 09 if the patient was admitted from
an institution that is engaged in providing, under the supervision of a physician,
any health and rehabilitative services for individuals who are intellectually disabled
(ID) or who have developmental disabilities (DD).
Response 10, Hospice: Select response 10 if the patient was admitted from
another hospice.
Response 99, None of the above: Select response 99 if the patient was admitted
from none of the above.
Item-Specific Tips
•
•
If the patient was in multiple settings prior to hospice admission, enter the
response that reflects where the patient was at the time of referral to hospice.
– For example, if a patient was referred to hospice in the hospital in the week
prior to admission to hospice and was discharged from the hospital to the
home 2 days prior to the start of hospice services, select response “5, Shortstay acute hospital,” because the patient was in the hospital at the time of
referral.
If the patient was enrolled in a hospice program and resided in the community,
select response “10, Hospice,” rather than response “01, Community residential
setting.”
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Chapter 2: Section A
Item-Specific Tips (continued)
•
•
The term “Admitted from” does not necessarily mean that the patient left the
facility to be admitted to hospice. The location immediately before admission may
be the same as immediately after (for example, a patient may be residing in a
long-term care facility and remain there during and after hospice admission), or
the two may be different (for example, a patient may elect hospice while in an
acute care hospital and begin receiving hospice services upon returning to their
home).
For purposes of completing Item A1802, SNF is not synonymous with nursing
facility. The response option for SNF is to be used for patients in a SNF or
patients in the SNF portion of a dually-certified nursing facility. If a beneficiary is in
a nursing facility but doesn't meet the criteria above, do not use the response
option for SNF; instead, use the response option for long-term care facility (also
known as NF or nursing facility).
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Chapter 2: Section A
A2115. Reason for Discharge
Enter Code
01.
02.
03.
04.
05.
06.
Expired
Revoked
No longer terminally ill
Moved out of hospice service area
Transferred to another hospice
Discharged for cause
Item-Specific Instructions
Complete only if A0250 = 09, Discharge
Review the clinical record, including the discharge plan and discharge order, for
documentation of discharge reason. Select the response that corresponds to the
patient’s reason for discharge.
•
Response 01, Expired: Select response 01 if the patient has died.
•
Response 02, Revoked: Select response 02 if the beneficiary has chosen
to revoke their hospice election.
– Response option 02, Revoked is also used for non-Medicare/Medicaid
patients who reject the hospice plan of care.
•
Response 03, No longer terminally ill: Select response 03 in the case of a
discharge when the hospice determines the beneficiary is no longer
terminally ill.
•
Response 04, Moved out of hospice service area: Select response 04 in
the case of a discharge when the beneficiary moves out of the hospice’s
service area.
•
Response 05, Transferred to another hospice: Select response 05 in the
case of a discharge when the beneficiary transfers to another hospice.
•
Response 06, Discharged for cause: Select response 06 in the case of a
discharge for cause.
– CMS defines discharge for cause as a discharge made because the
patient’s (or other persons in the patient’s home) behavior is disruptive,
abusive, or uncooperative to the extent that delivery of care to the
patient or the ability of the hospice to operate effectively is seriously
impaired.
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Chapter 2: Section F
SECTION F: PREFERENCES
Items in this section of the Hospice Item Set (HIS) pertain to the hospice patient’s
preferences regarding life-sustaining treatments and spiritual care. Preferences
are best obtained directly from the patient, or the caregiver or responsible party if
the patient cannot self-report. The items in this section do not represent an
exhaustive list of patient preferences that hospices should consider, and
completion of this section does not replace a thorough and ongoing discussion of
patient preferences throughout an episode of care.
SECTION F: RATIONALE
Seriously ill and dying patients who are given the opportunity to express their
preferences regarding life-sustaining treatment are more likely to receive care
consistent with their values, improving patient and family outcomes, including
greater satisfaction with care.
• Patients may come into hospice with documentation of preferences for lifesustaining treatment. However, pre-existing documentation may not reflect
their current preferences because patient preferences may change,
particularly as their condition changes.
Care for spiritual needs is a critical element of quality of life at the end of life.
Patients and/or caregivers should be given the opportunity to express their needs
for spiritual care to help ensure their needs are met.
• One of the unique aspects of hospice care is an interdisciplinary approach
toward providing care for the physical, psychosocial, and spiritual needs of
the patient and caregiver(s). Discussion of spiritual concerns is the core of a
rigorous assessment of spiritual care needs and is essential to assuring that
these needs are met.
Items in this section are intended to capture the process of eliciting patient
preferences; they are intended to capture evidence of discussion and/or
communication about patient preferences.
F2000. CPR Preference
Enter Code
A. Was the patient/responsible party asked about preference
regarding the use of cardiopulmonary resuscitation (CPR)? Select
the most accurate response.
0. No Skip to F2100, Other Life-Sustaining Treatment Preferences
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about
preference regarding the use of CPR:
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Chapter 2: Section F
Item-Specific Instructions
Review the clinical record for information regarding discussion of patient preference
for cardiopulmonary resuscitation (CPR). For this item, it is also permissible to
consider care processes documented in the clinical record that took place during preadmission or educational visits. Item completion should be based on what is included
in the clinical record. Review all response choices before making a selection.
F2000A: Was the patient/responsible party asked about preference regarding
the use of cardiopulmonary resuscitation (CPR)?
• Response 0, No: Select response 0 if there is no documentation that the
hospice discussed (or attempted to discuss) preference regarding the use of
CPR with the patient or responsible party. Skip to Item F2100, Other LifeSustaining Treatment Preferences.
– Response 0 applies to situations where there is no documentation that a
discussion occurred or was attempted with the patient or responsible party.
This could happen if the patient was unable to discuss and/or the
responsible party was unavailable.
• Response 1, Yes, and discussion occurred: Select response 1 if there is
documentation that the hospice discussed preference regarding the use of
CPR with the patient or responsible party.
– Response 1 applies to situations where there is documentation that the
hospice brought up the topic of CPR use and had a conversation with the
patient, the responsible party, or both. The conversation does not have to
result in the patient stating a preference for or against the use of CPR to
select response 1 for F2000A. For the purposes of Item F2000, select
response 1 if the hospice opened the door for a conversation and there is
documentation that the patient or responsible party engaged with the
hospice in a discussion regarding CPR.
• Response 2, Yes, but the patient/responsible party refused to discuss:
Select response 2 if there is documentation that the hospice asked about
preference regarding the use of CPR, but the patient or responsible party
refused to discuss or was unable to discuss.
– Response 2 applies to situations where there is documentation that the
hospice attempted to have a conversation with the patient and responsible
party, but both the patient and responsible party explicitly refused to discuss
the topic with the hospice. This would include statements such as “I don’t
want to talk about this” or “I’m only going to talk to my priest about this.” In
these instances, the hospice was not successful in engaging the patient
and/or responsible party in a discussion.
– Response 2 also applies to situations in which the hospice attempted to
discuss the topic, but the patient was unable to discuss because of their
clinical status and the responsible party explicitly refused to discuss.
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Chapter 2: Section F
Item-Specific Instructions (continued)
F2000B: Date the patient/responsible party was first asked about preference
regarding the use of CPR
• Enter the date the hospice first discussed (or attempted to discuss) patient
preference regarding the use of CPR. Use the format Month-Day-Year: MMDD-YYYY. If the month and/or day contain only a single digit, enter “0” in the
first box of the month and/or day. For example, November 1, 2021 would
be entered as 11-01-2021.
• It is possible that at the time of HIS completion, multiple discussions regarding
the use of CPR will be documented in the clinical record. Complete HIS items
based on the first dated discussion about preference regarding the use of CPR
that appears in the clinical record.
• For this item, it is permissible to consider care processes documented in the
clinical record at pre-admission or educational visits (before the Admission
Date). In these instances, use the date on which the discussion occurred for
F2000B.
Item-Specific Tips
F2000 asks whether or not the patient or responsible party was asked about
preference regarding the use of CPR. “Responsible party” refers to the legally
responsible or authorized individual, such as the Health Care Power of Attorney or
legal guardian. In cases where there is no legal guardian or power of attorney
identified, the hospice should use state law guidance to identify the appropriate
surrogate decision-maker.
• In order to report “Yes” to F2000A, if a party other than the patient was asked
about preference regarding the use of CPR, there must be evidence in the
clinical record that the responsible party as defined above was asked about
preferences.
F2000 is intended to capture evidence of a discussion (or attempted discussion)
about patient preference regarding the use of CPR.
• A discussion about CPR preference can be initiated by any member of the
hospice staff or interdisciplinary group (IDG).
• Orders alone or short statements in the clinical record, such as “DNR/DNI” or
“full code,” without evidence of discussion or involvement from
patient/responsible party, are not sufficient to report “Yes” for F2000A.
Evidence of a discussion could be documented in the clinical record or via a Do Not
Resuscitate (DNR) order, Physician Orders for Life-Sustaining Treatment (POLST)
order, or equivalent.
• A newly completed DNR order or POLST form that is signed by the hospice
clinician after the admission to hospice or during a preadmission visit is
sufficient to select response “1, Yes” for F2000A, provided there is evidence of
involvement from the patient/responsible party, such as signature of the patient
or responsible party on POLST forms, or clinical documentation, such as “DNR
preference confirmed with responsible party.”
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Chapter 2: Section F
Item-Specific Tips (continued)
•
If a patient is admitted to hospice with a pre-existing DNR order or POLST that
was signed in a prior care setting, the hospice should re-affirm the patient’s
preferences that appear in the pre-existing DNR order or POLST. This
reaffirmation should be documented in the clinical record. Clinical record
documentation, such as “discussed CPR preference during the admission visit
with patient,” is sufficient to select response “1, Yes.”
– If the clinical record is ambiguous as to whether the hospice attempted to
re-affirm patient preferences documented in a pre-existing DNR
order/POLST, select response “0, No” for F2000A and skip to Item F2100.
Examples
Situation A - Patient’s clinical record contains the following information:
Patient admitted on 08-01-2021. Clinical note dated 08-01-2021 shows, “talked
with patient about preference for CPR; patient states they are not sure. Requests
time to think and wants to discuss later.” Clinical note dated 08-05-2021 shows,
“discussed patient’s preference for CPR; patient stated preference for DNR. DNR
order signed and in clinical record.”
• HIS Response Selection:
F2000A: Was the patient/responsible party asked about preference
regarding the use of cardiopulmonary resuscitation (CPR)? Select response
“1, Yes, and discussion occurred.”
F2000B: Date the patient/responsible party was first asked about
preference regarding the use of CPR: Enter “08-01-2021.”
• Explanation: Although the patient later stated a preference regarding DNR on
8-05-2021, F2000 should be completed based on the first dated discussion in
the clinical record. The most appropriate response option for F2000A is “1”
because although at the first dated discussion the patient did not express a clear
preference regarding the use of CPR, a discussion did occur. Enter “08-01-2021”
for F2000B because it is the first dated discussion that appears in the clinical
record.
Situation B - Patient’s clinical record contains the following information:
Patient admitted 08-01-2021 Clinical record for the patient includes a DNR order,
signed in the prior care setting, which is dated 07-15-2021.
• HIS Response Selection:
F2000A: Was the patient/responsible party asked about preference
regarding the use of cardiopulmonary resuscitation (CPR)? Select response
“0, No.” Skip to Item F2100, Other Life-Sustaining Treatment Preferences.
• Explanation: Although the patient has a recently dated DNR order, it was signed
in a prior care setting. There is no documentation in the clinical record to indicate
that the hospice re-confirmed the patient’s preferences. If a statement such as
“DNR order confirmed with responsible party, patient’s daughter” was included,
that would be sufficient to select response “1, Yes, and discussion occurred.”
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Chapter 2: Section F
F2100. Other Life-Sustaining Treatment Preferences
Enter Code
A. Was the patient/responsible party asked about preferences
regarding life-sustaining treatments other than CPR? Select the
most accurate response.
0. No Skip to F2200, Hospitalization Preference
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about
preferences regarding life-sustaining treatments other than CPR:
Item-Specific Instructions
Review the clinical record for information regarding patient preference for lifesustaining treatment other than CPR. For this item, it is permissible to consider
care processes documented in the clinical record that took place during preadmission or educational visits. Item completion should be based on what is
included in the clinical record. Review all response choices before making a
selection.
F2100A: Was the patient/responsible party asked about preferences
regarding life-sustaining treatment other than CPR?
• Response 0, No: Select response 0 if there is no documentation that the
hospice discussed (or attempted to discuss) preferences regarding lifesustaining treatment other than CPR with the patient or responsible party.
Skip to Item F2200, Hospitalization Preference.
– Response 0 applies to situations where there is no documentation that a
discussion occurred or was attempted with the patient or responsible
party. This could happen if the patient was unable to discuss and/or the
responsible party was unavailable.
• Response 1, Yes, and discussion occurred: Select response 1 if there is
documentation that the hospice discussed preferences regarding lifesustaining treatment other than CPR with the patient or responsible party.
– Response 1 applies to situations where there is documentation that the
hospice brought up the topic of life-sustaining treatment other than CPR
and there was a conversation with the patient and/or responsible party.
The conversation does not have to result in the patient stating a
preference for or against the use of life-sustaining treatments other than
CPR to select response 1 for F2100A. For the purposes of Item F2100,
select response 1 if the hospice opened the door for a conversation and
there is documentation that the patient or responsible party engaged with
the hospice in a discussion regarding life-sustaining treatment
preferences other than CPR.
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Chapter 2: Section F
Item-Specific Instructions (continued)
Response 2, Yes, but the patient/responsible party refused to discuss:
Select response 2 if there is documentation that the hospice asked about
preferences regarding life-sustaining treatment other than CPR, but the patient
or responsible party refused to discuss or was unable to discuss.
– Response 2 applies to situations where there is documentation that the
hospice attempted to have a conversation with the patient and responsible
party, but both the patient and responsible party explicitly refused to discuss
the topic with the hospice. This would include statements such as “I don’t
want to talk about this” or “I’m only going to talk to my priest about this.” In
these instances, the hospice was not successful in engaging the patient
and/or responsible party in a discussion.
– Response 2 also applies to situations in which the hospice attempted to
discuss the topic, but the patient was unable to discuss because of their
clinical status and the responsible party explicitly refused to discuss.
F2100B: Date the patient/responsible party was first asked about preferences
regarding life-sustaining treatments other than CPR
• Enter the date the hospice first discussed (or attempted to discuss) patient
preferences regarding life-sustaining treatment other than CPR. Use the
format Month-Day-Year: MM-DD-YYYY. If the month and/or day contain only a
single digit, enter “0” in the first box of the month and/or day. For example,
November 1, 2021 would be entered as 11-01-2021.
• It is possible that at the time of HIS completion, multiple discussions regarding
the use of life-sustaining treatments other than CPR will be documented in the
clinical record. Complete HIS items based on the first dated discussion about
preference regarding life-sustaining treatment other than CPR that appears in
the clinical record.
• For this item, it is permissible to consider care processes documented in the
clinical record at pre-admission or educational visits (before the Admission
Date). In these instances, use the date on which the discussion occurred for
F2100B.
•
Item-Specific Tips
F2100 asks whether or not the patient or responsible party was asked about
preferences regarding life-sustaining treatments other than CPR. “Responsible party”
refers to the legally responsible or authorized individual, such as the Health Care
Power of Attorney or legal guardian. In cases where there is no legal guardian or
power of attorney identified, the hospice should use state law guidance to identify the
appropriate surrogate decision-maker.
• In order to report “Yes” to F2100A, if a party other than the patient was asked
about preferences regarding life-sustaining treatments other than CPR, there
must be evidence in the clinical record that the responsible party as defined
above was asked about preferences.
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Chapter 2: Section F
Item-Specific Tips (continued)
F2100 is intended to capture evidence of a discussion (or attempted discussion)
about patient preference regarding life-sustaining treatment other than CPR. Evidence
of a discussion could be documented in the clinical record or via a POLST order or
equivalent.
•
•
•
A discussion about preference for life-sustaining treatment other than CPR can
be initiated by any member of the hospice staff or IDG.
Orders alone, without evidence of discussion or involvement from
patient/responsible party, are not sufficient to report “Yes” for F2100A.
There is no comprehensive list of life-sustaining treatments. Documentation in
the clinical record indicating that a member of the hospice staff or IDG
attempted to discuss preference for any life-sustaining treatment other than
CPR (for example, ventilator support, tube feeding, dialysis, blood transfusion,
antibiotics, intravenous [IV] fluids) is sufficient to select either of the following
for F2100A:
– “1, Yes, and discussion occurred”
– “2, Yes, but patient/responsible party refused to discuss”
Evidence of a discussion could be documented in the clinical record or via a POLST
order or equivalent:
•
•
A newly completed POLST form that is signed by the hospice clinician after the
admission to hospice or during a preadmission visit is sufficient to select “1,
Yes” for F2100A, provided there is evidence of involvement from the
patient/responsible party, such as signature of the patient or responsible party
on POLST forms, or clinical documentation such as “treatment preference
confirmed with responsible party.”
If a patient is admitted to hospice with a pre-existing POLST that was signed in
a prior care setting, the hospice should re-affirm the patient’s preferences that
appear in the pre-existing POLST. This re-affirmation of preferences should be
documented in the clinical record. Clinical record documentation, such as
“discussed life-sustaining treatment preferences during the admission visit with
patient,” is sufficient to select response “1, Yes”.
– If the clinical record is ambiguous as to whether the hospice attempted to
re-affirm patient preferences in a pre-existing POLST, select response “0,
No” for F2100A and skip to Item F2200, Hospitalization Preference.
Examples
Situation A - Patient’s clinical record contains the following information:
Patient admitted on 08-01-2021. Clinical note dated 08-01-2021 shows, “Had
discussion with patient about preference for use of prolonged IV fluids; patient was
hesitant and stated they weren’t sure and wanted to discuss later. Told patient we
could discuss at later date.”
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Chapter 2: Section F
Examples (continued)
•
•
HIS Response Selection:
F2100A: Was the patient/responsible party asked about preference
regarding the use of any life-sustaining treatment other than CPR? Select
response “1, Yes, and discussion occurred.”
F2100B: Date the patient/responsible party was first asked about
preference regarding the use of CPR: Enter “08-01-2021.”
Explanation: The most appropriate response option for F2100A is “1” because
although the patient did not express a clear preference regarding use of
prolonged IV fluids, a discussion did occur.
Situation B - Patient’s clinical record contains the following information:
Patient admitted 08-01-2021. Clinical record for the patient includes an order from the
prior care setting, “no life-sustaining treatments desired,” which is dated 07-15-2021.
•
•
HIS Response Selection:
F2100A: Was the patient/responsible party asked about preference
regarding life-sustaining treatments other than CPR? Select response “0,
No.” Skip to Item F2200, Hospitalization Preference.
Explanation: Although the patient has a recently dated order regarding lifesustaining treatment preferences, it was signed in a prior care setting. There is
no documentation in the hospice clinical record to indicate that the hospice reconfirmed the patient’s preferences. If a statement such as “desire to avoid all
forms of life-sustaining treatments confirmed with responsible party, patient’s
daughter” was included, that would be sufficient to select response “1, Yes, and
discussion occurred.”
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Chapter 2: Section F
F2200. Hospitalization Preference
Enter Code
A. Was the patient/responsible party asked about preference
regarding hospitalization? Select the most accurate response.
0. No Skip to F3000, Spiritual/Existential Concerns
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about
preference regarding hospitalization:
Item-Specific Instructions
Review the clinical record for information regarding patient preference for
hospitalization. This is not referring to the patient's choice of a particular facility,
but rather if the patient/caregiver has a preference regarding hospitalization as a
care option to consider. Examples of discussions with the patient or family that
could be considered for this item include, but are not limited to:
1.) The patient and/or caregiver expressed the desire to keep the patient at
home and not to be transferred/admitted to a hospital again
2.) The patient and/or caregiver discussed specific situations in which they
feel hospitalization would be the preferred location for their care
3.) The patient or caregiver state that, at this time, they are unsure if being
transferred/admitted to a hospital for care is something they would
consider.
For this item, it is permissible to consider care processes (discussions)
documented in the clinical record that took place during pre-admission or
educational visits. Item completion should be based on what is included in the
clinical record. Review all response choices before making a selection. For the
purposes of this item, “hospitalization” does not include hospice care (such as
general inpatient or respite level of care) provided in a contracted acute care
settings or hospital-based inpatient hospice units.
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Chapter 2: Section F
Item-Specific Instructions (continued)
F2200A: Was the patient/responsible party asked about preference regarding
hospitalization?
• Response 0, No: Select response 0 if there is no documentation that the
hospice discussed (or attempted to discuss) preference regarding
hospitalization with the patient or responsible party. Skip to Item F3000,
Spiritual/Existential Concerns.
– Response 0 applies to situations where there is no documentation that a
discussion occurred or was attempted with the patient or responsible party.
This could happen if the patient was unable to discuss and/or the
responsible party was unavailable.
• Response 1, Yes, and discussion occurred: Select response 1 if there is
documentation that the hospice discussed preference regarding hospitalization
with the patient or responsible party.
– Response 1 applies to situations where there is documentation that the
hospice brought up the topic of hospitalization and had a conversation with
the patient and/or responsible party. The conversation does not have to
result in the patient stating a preference for or against hospitalization to
select response 1 for F2200A. For the purposes of Item F2200, select
response 1 if the hospice opened the door for a conversation and there is
documentation that the patient or responsible party engaged with the
hospice in a discussion regarding hospitalization.
• Response 2, Yes, but the patient/responsible party refused to discuss:
Select response 2 if there is documentation that the hospice asked about
preference regarding hospitalization, but the patient or responsible party
refused to discuss or was unable to discuss.
– Response 2 applies to situations where there is documentation that the
hospice attempted to have a conversation with the patient and responsible
party, but both the patient and responsible party explicitly refused to
discuss the topic with the hospice. This would include statements such as
“I don’t want to talk about this” or “I’m only going to talk to my priest about
this.” In these instances, the hospice was not successful in engaging the
patient and/or responsible party in a discussion.
– Response 2 also applies to situations in which the hospice attempted to
discuss the topic, but the patient was unable to discuss because of their
clinical status and the responsible party explicitly refused to discuss.
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Chapter 2: Section F
Item-Specific Instructions (continued)
F2200B: Date the patient/responsible party was first asked about preference
regarding hospitalization
• Enter the date the hospice first discussed (or attempted to discuss) patient
preference regarding hospitalization. Use the format Month-Day-Year: MMDD-YYYY. If the month and/or day contain only a single digit, enter “0” in the
first box of the month and/or day. For example, November 1, 2021 would
be entered as 11-01-2021.
• It is possible that at the time of HIS completion, multiple discussions regarding
hospitalization preferences will be documented in the clinical record. Complete
HIS items based on the first dated discussion about preference regarding
hospitalization that appears in the clinical record.
• For this item, it is permissible to consider care processes documented in the
clinical record at pre-admission or educational visits (before the Admission
Date). In these instances, use the date on which the discussion occurred for
F2200B.
Item-Specific Tips
F2200 asks whether or not the patient or responsible party was asked about
preferences regarding hospitalization. “Responsible party” refers to the legally
responsible or authorized individual, such as the Health Care Power of Attorney or
legal guardian. In cases where there is no legal guardian or power of attorney
identified, the hospice should use state law guidance to identify the appropriate
surrogate decision-maker.
• In order to report “Yes” to F2200A, if a party other than the patient was asked
about preference regarding hospitalization, there must be evidence in the
clinical record that the responsible party as defined above was asked about
preferences.
F2200 is intended to capture evidence of a discussion (or attempted discussion)
about patient preference regarding hospitalization.
• A discussion about hospitalization preference can be initiated by any member
of the hospice staff or IDG.
Evidence of a discussion could be documented in the clinical record or via a POLST
form:
• A newly completed POLST form that is signed by the hospice clinician after the
admission to hospice or during a preadmission visit is sufficient to report “1,
Yes” for F2200A, provided there is evidence of involvement from the
patient/responsible party, such as the signature of the patient or responsible
party on POLST forms, or clinical documentation, such as “hospitalization
preference confirmed with responsible party.”
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Chapter 2: Section F
Item-Specific Tips (continued)
•
If a patient is admitted to hospice with a pre-existing POLST that was signed in
a prior care setting, the hospice should re-affirm the patient’s preferences that
appear in the pre-existing POLST. This re-affirmation of preferences should be
documented in the clinical record. Clinical record documentation, such as
“discussed preference regarding hospitalization during the admission visit with
patient,” is sufficient to select response “1, Yes.”
– If the clinical record is ambiguous as to whether the hospice attempted to
re-affirm patient preferences present in a pre-existing POLST, select
response “0, No” for F2200A and skip to Item F3000, Spiritual/Existential
Concerns.
Examples
Situation A - Patient’s clinical record contains the following information:
Patient admitted on 08-01-2021. Clinical note dated 08-01-2021 shows, “Talked
with patient about preference for readmission to hospital; patient was hesitant and
stated they weren’t sure. Told patient we could discuss at later date.”
•
HIS Response Selection:
F2200A: Was the patient/responsible party asked about preference
regarding hospitalization? Select response “1, Yes, and discussion
occurred.”
F2200B: Date the patient/responsible party was first asked about
preference regarding hospitalization: Enter “08-01-2021”
•
Explanation: The most appropriate response option for F2200A is “1” because
although the patient did not express a clear preference regarding
hospitalization, a discussion occurred.
Situation B - Patient’s clinical record contains the following information:
Patient admitted 08-01-2021. Clinical record for the patient includes a POLST
form completed in the prior care setting indicating selection of comfort-oriented
care, including desire to avoid hospitalization, which is dated 07-15-2021.
•
HIS Response Selection:
F2200A: Was the patient/responsible party asked about preference
regarding hospitalization? Select response “0, No.” Skip to Item F3000,
Spiritual/Existential Concerns.
•
Explanation: Although the patient has a recently dated POLST, it was signed
in a prior care setting. There is no documentation in the clinical record to
indicate that the hospice re-confirmed the patient’s preferences for comfortoriented care and avoidance of hospitalization. If a statement such as “All
POLST treatment preferences confirmed with responsible party, patient’s
daughter” was included, that would be sufficient to select response “1, Yes.”
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Chapter 2: Section F
F3000. Spiritual/Existential Concerns
Enter Code
A. Was the patient and/or caregiver asked about spiritual/existential
concerns? Select the most accurate response.
0. No Skip to I0010, Principal Diagnosis
1. Yes, and discussion occurred
2. Yes, but the patient and/or caregiver refused to discuss
B. Date the patient and/or caregiver was first asked about
spiritual/existential concerns:
Item-Specific Instructions
Review the clinical record for information regarding spiritual/existential concerns.
For this item, it is permissible to consider care processes documented in the clinical
record that took place during pre-admission or educational visits. Item completion
should be based on what is included in the clinical record. Do not use sources
external to the clinical record. Review all response choices before making a
selection.
F3000A: Was the patient and/or caregiver asked about spiritual/existential
concerns?
•
Response 0, No: Select response 0 if there is no documentation that the
hospice discussed (or attempted to discuss) spiritual/existential concerns
with the patient and/or caregiver(s). Skip to Item I0010, Principal Diagnosis.
– Response 0 applies to situations where there is no documentation that a
discussion occurred or was attempted with the patient and/or caregiver.
This could happen if the patient was unable to discuss and/or the
caregiver was unavailable.
•
Response 1, Yes, and discussion occurred: Select response 1 if there is
documentation that the hospice discussed spiritual/existential concerns with
the patient and/or caregiver(s).
– Response 1 applies to situations where there is documentation that the
hospice brought up the topic of spiritual/existential concerns and there
was a conversation with the patient and/or caregiver. The conversation
does not have to result in initiation of intervention(s) to address
spiritual/existential concerns to select response 1 for F3000A. For the
purposes of Item F3000, select response 1 if the hospice opened the
door for a conversation and there is documentation that the patient
and/or caregiver engaged with the hospice in a discussion regarding
spiritual/existential concerns.
•
Response 2, Yes, but patient and/or caregiver refused to discuss:
Select response 2 if there is documentation that the hospice asked about
spiritual/existential concerns, but the patient and/or caregiver(s) refused to
discuss or were unable to discuss.
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Chapter 2: Section F
Item-Specific Instructions (continued)
– Response 2 applies to situations where there is documentation that the
hospice attempted to have a conversation with the patient and caregiver,
but both the patient and caregiver explicitly refused to discuss the topic with
the hospice. This would include statements such as “I don’t want to talk
about this” or “I’m only going to talk to my priest about this.” In these
instances, the hospice was not successful in engaging the patient and/or
caregiver in a discussion.
– Response 2 also applies to situations in which the hospice attempted to
discuss the topic, but the patient was unable to discuss because of their
clinical status and the caregiver explicitly refused to discuss.
F3000B: Date the patient and/or caregiver was first asked about
spiritual/existential concerns
• Enter the date the hospice discussed (or attempted to discuss)
spiritual/existential concerns. Use the format Month-Day-Year: MM-DD-YYYY.
If the month and/or day contain only a single digit, enter “0” in the first box of
the month and/or day. For example, November 1, 2021 would be entered as
11-01-2021.
• It is possible that at the time of HIS completion, multiple discussions regarding
spiritual/existential concerns will be documented in the clinical record.
Complete HIS items based on the first dated discussion about
spiritual/existential concerns that appears in the clinical record.
Item-Specific Tips
F3000 asks whether the patient and/or caregiver was asked about spiritual/existential
concerns. For the purposes of completing Item F3000, “caregiver” does not have to
be the legally authorized representative.
F3000 is intended to capture evidence of a discussion (or attempted discussion) of
spiritual/existential concerns with the patient and/or caregiver(s). This item does not
capture whether interventions to address concerns were initiated.
• There is no comprehensive list of spiritual/existential concerns. Examples of a
discussion regarding spiritual/existential concerns might include, but are not
limited to, asking the patient/caregiver about need for spiritual or religious
support, asking questions about the cause or meaning of illness or death,
having a discussion about a higher power related to illness, or offering a
spiritual resource (such as a chaplain). Documentation in the clinical record
indicating that a member of the hospice staff or IDG attempted to discuss
spiritual/existential concerns is sufficient to select either of the following for
F3000A:
– “1, Yes, and discussion occurred”
– “2, Yes, but the patient and/or caregiver refused to discuss”
• Brief statements or data in the clinical record denoting a patient’s religious
affiliation is not sufficient to select “Yes” for F3000A.
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Chapter 2: Section F
Item-Specific Tips (continued)
•
Brief statements or data in the clinical record that denotes a spiritual visit was
offered without documentation of a discussion is not sufficient to select “Yes”
for F3000A.
•
If clinical record documentation is ambiguous as to whether discussion about
spiritual/existential concerns was attempted, select response “0, No” for
F3000A and skip to Item I0010, Principal Diagnosis.
While these conversations are best held face-to-face, phone conversations with
patients/families about spiritual/existential issues can be used to answer yes to F3000
as long as the clinical documentation supports that a discussion was had with the
patient and/or caregiver.
A discussion with the patient and/or caregiver(s) about spiritual/existential concerns
can be initiated by any member of the hospice staff or IDG.
Examples
Situation A - Patient’s clinical record contains the following information:
Social worker questionnaire dated 08-01-2021 shows, “Patient’s spouse in great
deal of spiritual distress and would like to speak with chaplain. Referral made.”
•
HIS Response Selection:
F3000A: Was the patient and/or caregiver asked about spiritual/existential
concerns? Select response “1, Yes, and discussion occurred.”
F3000B: Date the patient and/or caregiver was first asked about spiritual/
existential concerns. Enter “08-01-2021.”
•
Explanation: The completed questionnaire is strong evidence that the hospice
engaged the patient and/or caregiver in a discussion regarding
spiritual/existential concerns. Even though the clinical record does not contain
documentation of a visit by the chaplain, select response “1, Yes, and
discussion occurred” for F3000A because the intent of F3000 is to capture
initiation of a discussion about spiritual/existential concerns.
Situation B - Patient’s clinical record contains the following information:
Patient’s initial assessment shows, “patient identifies their religious affiliation as
Baptist.”
•
HIS Response Selection:
F3000A: Was the patient and/or caregiver asked about spiritual/existential
concerns? Select response “0, No” and skip to Item I0010, Principal
Diagnosis.
•
Explanation: The intent of F3000 is to capture initiation of a discussion (or
attempted discussion) about spiritual/existential concerns. Clinical record
documentation showing only the patient’s religious affiliation is not sufficient
evidence that the hospice had (or attempted to have) a discussion regarding
spiritual/existential concerns with the patient and/or caregiver.
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Chapter 2: Section I
SECTION I: ACTIVE DIAGNOSES
Items in this section of the Hospice Item Set (HIS) pertain to principal diagnosis of
the patient. This section has only one item, I0010, Principal Diagnosis.
Disclaimer: The HIS is intended for use in quality reporting; it does not imply
acceptability for payment purposes.
SECTION I: RATIONALE
Disease processes and conditions can impact service delivery. This section
includes the most common principal diagnoses among hospice patients.
I0010. Principal Diagnosis
Enter Code
01. Cancer
02. Dementia/Alzheimer’s
99. None of the above
Item-Specific Instructions
Review the clinical record for information regarding principal diagnosis. Item
completion must be based on what is indicated in the clinical record. Do not use
sources external to the clinical record. Review all response choices before making
a selection. This item should be completed based on the patient’s principal
diagnosis at the time of admission to hospice.
I0010: Principal Diagnosis
•
•
•
Response 01, Cancer: Select response 01 if the patient’s principal
diagnosis is cancer (including leukemia).
Response 02, Dementia/Alzheimer’s: Select response 02 if the patient’s
principal diagnosis is dementia (Alzheimer’s Disease; frontotemporal
dementia; Pick’s disease; other frontotemporal dementia; senile
degeneration of brain; dementia with Lewy bodies). Note that some
dementia codes have ICD-9-CM and ICD-10-CM manifestation/etiology or
sequencing conventions; ensure that coding guidelines have been met for
reporting principal diagnosis.
Response 99, None of the above: Select response 99 if the patient’s
principal diagnosis is a disease or condition other than cancer or
dementia/Alzheimer’s.
Item-Specific Tips
The principal diagnosis is defined as the condition established after study to be
chiefly responsible for the patient’s admission. For hospice patients, this is the
diagnosis most contributory to the patient having a life expectancy of 6 months or
less if the illness runs its normal course.
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HIS Manual
Chapter 2: Section J
SECTION J: HEALTH CONDITIONS
Items in this section of the Hospice Item Set (HIS) pertain to physical symptom
management for hospice patients. Physical symptoms included in this section are
pain and shortness of breath.
SECTION J, PAIN: RATIONALE
Pain is prevalent and undertreated for many populations of seriously ill patients,
including those patients nearing the end of life. Patients and family caregivers rate
pain management as a high priority when living with serious and life-limiting
illnesses. The consequences of inadequate screening, assessment, and treatment
for pain include physical suffering, functional limitation, and development of apathy
and depression.
•
•
Inclusion of pain screening items will improve awareness of the presence of
pain, which is the first essential step for quality pain management and
treatment.
Inclusion of pain assessment items will improve awareness of assessment of
pain severity, etiology, and effect on function, which is the second step for
quality pain management and treatment.
J0900. Pain Screening
Enter Code
A. Was the patient screened for pain?
0. No Skip to J0905, Pain Active Problem
1. Yes
B. Date of first screening for pain:
Enter Code
C. The patient’s pain severity was:
0. None
1. Mild
2. Moderate
3. Severe
9. Pain not rated
D. Type of standardized pain tool used:
1. Numeric
2. Verbal descriptor
3. Patient visual
4. Staff observation
9. No standardized tool used
Enter Code
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Chapter 2: Section J
Item-Specific Instructions
Review the clinical record for information regarding pain screening. Item completion
should be based on what is included in the clinical record. Do not use sources
external to the clinical record. Review all response choices before making a selection.
Consider results of the standardized pain screening tool and any other screening
approaches the clinician used that might include asking the patient about their pain
comfort.
J0900A: Was the patient screened for pain?
• Response 0, No: Select response 0 if there is no documentation that the
patient was screened for pain. Skip to Item J0905, Pain Active Problem.
• Response 1, Yes: Select response 1 if there is documentation that the patient
was screened for pain.
J0900B: Date of first screening for pain
• Enter the date of the first screening for pain. Use the format Month-DayYear: MM-DD-YYYY. If the month and/or day contain only a single digit, enter a
“0” in the first box of the month and/or day. For example, November 1, 2021
would be entered as 11-01-2021.
• It is possible that at the time of HIS completion, multiple pain screenings will be
documented in the clinical record. Complete HIS pain screening items based
on the first pain screening documented in the clinical record.
J0900C: The patient’s pain severity was
• Response 0, None: Select response 0 if the patient’s pain severity score was
none. This would include a score of 0 on a 10-point numeric scale or equivalent
on verbal, visual, other numeric, or staff observation scale.
• Response 1, Mild: Select response 1 if the patient’s pain severity score was
mild. This would include a score of 1–3 on a 10-point numeric scale or
equivalent on verbal, visual, other numeric, or staff observation scale.
• Response 2, Moderate: Select response 2 if the patient’s pain severity score
was moderate. This would include a score of 4–6 on a 10-point numeric scale
or equivalent on verbal, visual, other numeric, or staff observation scale.
• Response 3, Severe: Select response 3 if the patient’s pain severity score was
severe. This would include a score of 7–10 on a 10-point numeric scale or
equivalent on verbal, visual, other numeric, or staff observation scale.
• Response 9, Pain not rated: Select response 9 if the patient had pain, but the
patient’s pain severity was not assessed or recorded.
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Chapter 2: Section J
Item-Specific Instructions (continued)
J0900D: Type of standardized pain tool used
• Response 1, Numeric: Select response 1 if a numeric scale was used to
conduct pain screening.
– Examples of standardized numeric scales include but are not limited to, 10point scale, the Symptom Distress Scale (McCorkle), the Memorial
Symptom Assessment Scale (MSAS), and the Edmonton Symptom
Assessment System (ESAS).
• Response 2, Verbal descriptor: Select response 2 if a verbal descriptor scale
was used to conduct pain screening.
– Examples of standardized verbal descriptor scales include, but are not
limited to, the Brief Pain Inventory, the McGill pain questionnaire, and the 6Point Verbal Pain Scale.
• Response 3, Patient visual: Select response 3 if a patient visual scale was
used to conduct pain screening.
– Examples of standardized patient visual scales include, but are not limited
to, the Wong-Baker FACES Pain Scale, a visual analog scale, and a
distress thermometer.
• Response 4, Staff observation: Select response 4 if a staff observational
scale was used to conduct pain screening. Select response 4 only if a
standardized staff observational scale was used.
– Examples of standardized staff observation scales include, but are not
limited to, the Critical Care Pain Observation Tool (CPOT), the Checklist of
Nonverbal Pain Indicators (CNPI), the Pain Assessment Checklist for
Seniors with Limited Ability to Communicate (PACSLAC), and Pain
Assessment in Advanced Dementia (PAIN-AD).
• Response 9, No standardized tool used: Select response 9 if no
standardized scale was used to screen for the presence and severity of pain.
Item-Specific Tips
Pain screening includes evaluating the patient for presence of pain, and if pain is
present, rating its severity using a standardized tool. A standardized tool is one that
(1) has been scientifically tested on a population with characteristics similar to that of
the patient being assessed (for example, community-dwelling elderly, noninstitutionalized adults with disabilities), and (2) includes a standard response scale
(for example, a scale where patients rate pain from 0–10). The standardized tool must
be appropriately administered as indicated in the instructions and must be relevant for
the patient's ability to respond.
• Select the best response for pain severity based on the pain level at the time of
the visit during which the screening was performed. If a range is provided,
such as mild to moderate, report the highest level of severity experienced
during the visit.
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Chapter 2: Section J
Item-Specific Tips (continued)
•
If a non-numeric scale was used to screen the patient for pain, select the pain
severity item based on the standard established for that scale. If no standard
has been established for that scale, use clinician judgment to categorize
severity.
If the screening indicated the patient was not in pain, the clinician may not have used
a standardized pain tool to determine presence and severity of pain.
• If documentation in the patient’s clinical record indicates the patient was
assessed clinically and was found to have no pain, but no standardized pain
tool was used to screen the patient, the best course of action is to select
response “1, Yes” for J0900A, enter the date for J0900B, select response “0,
None” for J0900C pain severity, and select response 9, No standardized tool
used for J0900D.
If documentation in the patient’s clinical record indicates the patient has been clinically
evaluated for pain and was found to be in pain, but it is ambiguous as to whether a
screening was conducted using a standardized pain tool (with which severity of pain
was also noted), the best course of action is to select response “1, Yes” for J0900A,
enter the date for J0900B, and select response “9” for J0900C and J0900D.
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Chapter 2: Section J
J0905. Pain Active Problem
Enter Code
Is pain an active problem for the patient?
0. No Skip to J2030, Screening for Shortness of Breath
1. Yes
Item-Specific Instructions
J0905. Pain Active Problem
•
Response 0, No: Select response 0 if pain is not an active problem for the
patient.
•
Response 1, Yes: Select response 1 if pain is an active problem for the
patient.
Item-Specific Tips
•
•
•
•
The determination of whether or not pain is an active problem may be made by
the assessing clinician, based on patient-specific findings. In determining
whether pain is an active problem for the patient, clinicians may need to
consider factors beyond pain severity at the time of the clinical encounter, such
as historical report of pain, reports of recent symptoms, current treatment for
pain (pharmacologic and/or non-pharmacologic), etc. It is possible that the
clinician may determine pain is an active problem for the patient, even if
pain is not present during the clinical encounter.
If documentation in the patient’s clinical record indicates that pain is an active
problem for the patient, then select 1, Yes to J0905, and continue to Item
J0910, Comprehensive Pain Assessment and complete J0910 according to
item completion instructions. If documentation in the patient’s clinical record
indicates that pain is not an active problem for the patient, then select 0, No to
J0905, and for the purposes of completing the HIS, skip item J0910. Therefore,
in instances where the patient is not in pain at the time of the screening, but
pain is an active problem for the patient, the HIS directs you to complete Item
J0910.
Generally, clinical documentation that the patient is currently taking pain
medication is evidence that pain is an active problem for the patient.
Comfort kits or pre-printed admission orders alone are insufficient evidence to
determine pain is an active problem. For comfort kits and pre-printed admission
orders, treatment is not considered initiated until the hospice has received the
order and there is documentation that the patient/caregiver was instructed to
begin use of the medication or treatment; thus, proactive education on
medications in a comfort kit in anticipation of symptoms alone is insufficient
evidence to determine pain is an active problem.
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Chapter 2: Section J
J0910. Comprehensive Pain Assessment
Enter Code
A. Was a comprehensive pain assessment done?
0. No Skip to J2030, Screening for Shortness of Breath
1. Yes
B. Date of comprehensive pain assessment:
C. Comprehensive pain assessment included:
Check all that apply
1. Location
2. Severity
3. Character
4. Duration
5. Frequency
6. What relieves/worsens pain
7. Effect on function or quality of life
9. None of the Above
Item-Specific Tips
A comprehensive pain assessment should address multiple aspects of pain, beyond
a determination of the presence of pain and its severity.
It is possible to include elements of the pain assessment listed in J0910C for
nonverbal patients.
• A caregiver report about any of the above characteristics is acceptable.
Clinical notes about assessment of nonverbal indicators of pain for any of the
above characteristics are also acceptable.
• Nonverbal indicators of pain include nonverbal sounds such as crying,
whining, and groaning; facial expressions, such as grimacing and clenching
jaws; and protective body movements or postures such as bracing, guarding,
rubbing, or clutching a body part. For example:
– An assessment that included pain location for a nonverbal patient may
include documentation, such as “patient grimaced and shouted when
clinician touched their right leg” or other documentation denoting patient
exhibiting nonverbal cues of pain for a specific location on the body.
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Chapter 2: Section J
Item-Specific Tips (continued)
– An assessment that included pain severity for a nonverbal patient may
include documentation about intensity of nonverbal expressions of pain
(grimaces, winces, and clenched teeth/jaw) or protective body movements
(bracing, guarding, rubbing, clutching, or holding of a certain body
part/area). It could also include documentation of severity using a nonverbal
standardized rating scale.
– An assessment that included pain duration for a nonverbal patient may
include documentation about how long a patient exhibits any nonverbal
cues of pain, such as “patient cradled right arm throughout entire visit.”
– An assessment that included pain frequency for a nonverbal patient may
include documentation about how often a patient exhibits any nonverbal
cues of pain, such as most of the time, only at night, intermittently.
– An assessment that included what relieves/worsens pain for a nonverbal
patient may include documentation about actions, activities, or positions
that relieve/worsen pain, such as “patient exhibits fewer nonverbal signs of
pain when sitting up versus lying down.”
– An assessment that included pain’s effect on function or quality of life for a
nonverbal patient may include documentation about change in patient
activity, such as “family caregiver reports that patient is no longer able to sit
up in bed without moaning.”
For any of the seven characteristics included in the pain assessment, select response
options based on whether the clinician made an attempt to gather the information
from the patient/caregiver.
• For example, if, for a nonverbal patient, the clinician asked the family/caregiver
about pain location and the family/caregiver responded “I’m not sure” or “I don’t
know,” “1, Location” should be checked for J0910C because the clinician
attempted to gather the information.
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Chapter 2: Section J
Examples
Situation A – Patient’s clinical record contains the following information:
Clinical note dated 08-12-2021 shows, “patient stated he was not in pain today; no
complaints from patient or family. Patient reports he has recently taken a dose of his
pain medication. Patient states he has a history of pain, that comes and goes
intermittently and at its worst, pain is 6/10 and is a dull, aching pain in lower abdomen.
Historically, pain is worse when patient walks and pain is better when lying down.”
• HIS Response Selection:
J0900A: Was the patient screened for pain? Select response “1, Yes.”
J0900B: Date of first screening for pain: Enter “08-12-2021.”
J0900C: The patient’s pain severity was: Select response “0, None”
J0900D: Type of Standardized pain tool used: Select response “9, No
standardized tool used
J0905: Pain Active Problem Select response “1, Yes”.
J0910A: Was a comprehensive pain assessment done? Select response
“1, Yes.”
J0910B: Date of comprehensive pain assessment: Enter “08-12-2021.”
J0910C: Comprehensive pain assessment included: Check “1,
Location” (lower abdomen); Check “2, Severity” (currently not in pain, but at its
worst, pain is 6/10); Check “3, Character” (dull, aching pain); Check “5,
Frequency” (intermittent); Check “6, What relieves/worsens pain” (worse when
patient walks and pain is better when lying down);
• Explanation: Item J0900. Pain Screening should be completed based on the
patient’s pain status and assessment at the time of the screening clinical
encounter. This means that, although the patient reported a history of pain,
item J0900 should be completed based on the clinician’s assessment that the
patient was not in any pain at the time of the visit. Additionally, although there
was no standardized pain tool used to screen the patient at the time of the
screening clinical encounter, it is evident that the clinician evaluated the patient
and determined the patient was not in any pain. The correct course of action is
to complete J0900A-D. Item J0905. Pain Active Problem considers factors
beyond pain severity at the time of the screening clinical encounter, such as
historical report of pain or report of recent symptoms. In this situation, because
the patient has a history of pain, it is clinically appropriate for the clinician to
consider pain to be an active problem for the patient, and select “1, Yes” for
Item J0905. Pain Active Problem. Since pain is an active problem for the
patient, it is clinically appropriate for the clinician to complete a comprehensive
pain assessment (even though the patient was not in pain at the time of the
pain screening). Because at least one of the seven characteristics of a
comprehensive pain assessment were clearly documented, select response “1,
Yes” for J0910A and continue to J0910B-J0910C, selecting responses based
on documentation found in the clinical record.
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Chapter 2: Section J
Situation B – Patient’s clinical record contains the following information:
Clinical note dated 08-12-2021 shows, “patient unable to speak; observed during 20
minute evaluation; pain severity on nonverbal scale moderate to severe. Asked
patient’s family about how long patient had been in distress—family stated patient had
been moaning all morning, and rarely looked comfortable. Family stated patient often
clutches lower abdomen when touched. Unable to move patient because of signs of
distress when turning or attempting to get up from bed. Family uncertain what makes
pain worse or better.”
• HIS Response Selection:
J0900A: Was the patient screened for pain? Select response “1, Yes.”
J0900B: Date of first screening for pain: Enter “08-12-2021.”
J0900C: The patient’s pain severity was: Select response “3, Severe.”
J0900D: Type of Standardized pain tool used: Select response “4, Staff
observation.”
J0905: Pain Active Problem Select response “1, Yes”.
J0910A: Was a comprehensive pain assessment done? Select response
“1, Yes.”
J0910B: Date of comprehensive pain assessment: Enter “08-12-2021.”
J0910C: Comprehensive pain assessment included: Check “1, Location”
(clutching lower abdomen); check “2, Severity” (pain severity on nonverbal
scale moderate to severe); check “4, Duration” (patient had been moaning all
morning); check “5, Frequency” (rarely looked comfortable); check “6, What
relieves/worsens pain” (family uncertain); and check “7, Effect on function or
quality of life” (unable to move because of distress).
• Explanation: Item J0900. Pain Screening should be completed based on the
patient’s pain status and assessment at the time of the screening clinical
encounter. It is evident that the patient was in pain, and that the clinician
evaluated the patient’s pain and noted pain severity. Although the clinical tool is
not named, it is still evident that the clinician used a standardized approach or
clinical protocol to screen the patient. For J0900C, the correct course of action
is to select response “3, Severe,” based on the highest severity of pain at the
time of the visit. For Item J0905, clinical documentation that the patient was in
pain at the time of the screening visit is evidence that pain is an active problem
for the patient. For Item J0910, because at least one of the seven
characteristics of a comprehensive pain assessment were clearly documented
in the patient’s clinical record, select response “1, Yes” for J0910A and
continue to J0910B-J0910C, selecting responses based on documentation in
the clinical record. Even though the family stated they were not sure what made
the pain better or worse, “6, What relieves/worsens pain” can still be checked
because there was documentation that the clinician asked about what relieves
or worsens pain.
Situation C - Patient’s clinical record contains the following information:
Clinical documentation dated 08-14-2021 shows patient very drowsy; appears to be
comfortable during visit. No nonverbal signs of pain observed during the visit.
However, patient family reported that the patient is not allowing necessary dressing
changes or incontinence/skin care because the patient cannot tolerate the pain that
(continued)
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Chapter 2: Section J
each intervention causes. Patient family explained that the patient loudly
moans/grimaces during weekly dressing changes and incontinence/skin care about 6
times per day and that now the patient won’t let them do any more dressing changes
or skin care. The family explained that sometimes it was helpful to play music and talk
to the patient to try to distract them during dressing changes and skin care, and that
once the dressing change/skin care has been completed, the patient no longer
appears to be in pain. Family reports that the patient has no other pain except that
caused by dressing and/or incontinence/skin care interventions.
• HIS Response Selection:
J0900A: Was the patient screened for pain? Select response “1, Yes.”
J0900B: Date of first screening for pain: Enter “08-14-2021.”
J0900C: The patient’s pain severity was: Select response “0, None” J0900D:
Type of Standardized pain tool used: Select response “9, No standardized
tool used”.
J0905: Pain Active Problem: Select response “1, Yes”.
J0910A: Was a comprehensive pain assessment done? Select response
“1, Yes.”
J0910B: Date of comprehensive pain assessment: Enter “08-14-2021.”
J0910C: Comprehensive pain assessment included: Check “2, Severity”
(loudly moans/grimaces); check “4, Duration” (throughout dressing change/skin
care and that once the dressing change/skin care is completed, the patient no
longer appears to be in pain); check “5, Frequency” (during weekly dressing
changes and incontinence/skin care about 6 times per day); check “6, What
relieves/worsens pain” (dressing changes/skin care makes pain worse and
playing music and distraction makes pain better); Check “7, Effect on function or
quality of life” (patient no longer allowing dressing changes or skin care).
Explanation: Item J0900. Pain Screening should be completed based on the
patient’s pain status at the time of the screening clinical encounter. This means that
although the patient experiences pain during dressing changes/skin care, because the
clinician evaluated the patient and determined the patient was not in any pain, item
J0900 should be completed based on the clinician’s assessment that the patient was
not in any pain at the time of the screening clinical encounter. Although there was no
standardized pain tool used to screen the patient, it is evident the clinician evaluated
the patient and determined the patient was not in any pain at the time of the
screening. For Item J0905, although the patient family reports no pain other than pain
caused during dressing changes and/or incontinence/skin care, it is evident that pain
is interfering with clinical care and potentially affecting the patient’s quality of life.
Thus, in this situation, pain is considered an active problem. For Item J0910, since
pain is an active problem for the patient, it is clinically appropriate for the clinician to
complete a comprehensive pain assessment (even though the patient was not in pain
at the time of the pain screening). Because at least one of the seven characteristics of
a comprehensive pain assessment were clearly documented, select response “1,
Yes” for J0910A and continue to J0910B-J0910C, selecting responses based on
documentation found in the clinical record.
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Chapter 2: Section J
SECTION J, RESPIRATORY STATUS: RATIONALE
Shortness of breath (dyspnea) is prevalent and often under-treated among patients
nearing the end of life.
• Screening for shortness of breath is necessary to determine its presence
and severity, and screening forms the basis for treatment decision making.
Shortness of breath can be functionally limiting and distressing to patients and their
families/caregivers.
• Effective treatment is available to alleviate symptom distress.
• Treatment can include pharmacologic and non-pharmacologic interventions.
• Treatment for shortness of breath will vary in severity and etiology, and with
patient and caregiver preferences.
J2030. Screening for Shortness of Breath
Enter Code
A. Was the patient screened for shortness of breath?
0. No Skip to N0500, Scheduled Opioid
1. Yes
B. Date of first screening for shortness of breath:
Enter Code
C. Did the screening indicate the patient had shortness of breath?
0. No Skip to N0500, Scheduled Opioid
1. Yes
Item-Specific Instructions
Review the clinical record for documentation of screening for shortness of breath.
Item completion should be based on what is included in the clinical record. Do not
use sources external to the clinical record. Review all response choices before
making a selection.
J2030A: Was the patient screened for shortness of breath?
• Response 0, No: Select response 0 if there is no documentation that the
patient was screened for shortness of breath. Skip to Item N0500,
Scheduled Opioid.
• Response 1, Yes: Select response 1 if there is documentation that the
patient was screened for shortness of breath.
J2030B: Date of first screening for shortness of breath
• Enter the date the hospice first screened the patient for shortness of
breath. Use the format Month-Day-Year: MM-DD-YYYY. If the month and/or
day contain only a single digit, enter a “0” in the first box of the month and/or
day. For example, November 1, 2021 would be entered as 11-01-2021
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Chapter 2: Section J
Item-Specific Instructions (continued)
•
It is possible that at the time of HIS completion, multiple screenings for
shortness of breath will be documented in the clinical record. Complete HIS
shortness of breath screening items based on the first shortness of breath
screening that appears in the clinical record.
J2030C: Did the screening indicate the patient had shortness of breath?
• Response 0, No: Select response 0 if the screening indicated that the patient
did not have shortness of breath. Skip to Item N0500, Scheduled Opioid.
• Response 1, Yes: Select response 1 if the screening indicated that the patient
had shortness of breath.
Item-Specific Tips
A screening for shortness of breath must include evaluating the patient for
presence/absence of shortness of breath and, if shortness of breath is present, rating
its severity. Structured clinical evaluation for shortness of breath is not well defined;
therefore, documentation found in the clinical record for screening of shortness of
breath may vary and may not include use of a standardized tool for rating severity.
• To answer “yes” to J2030A, clinical record documentation must show that the
patient was screened for presence/absence of shortness of breath, and, if the
patient was found to be short of breath, there must also be evidence that
severity was rated in any manner clinically appropriate for the patient (which
may/may not have included the use of a standardized tool to rate severity).
• If documentation indicates the patient had shortness of breath, but severity was
not evaluated in any manner, answer “no” to J2030A.
Evidence of a “positive” screen for shortness of breath should consider whether
shortness of breath was an active problem for the patient at the time of the screening
clinical encounter. In determining whether shortness of breath was an active problem
for the patient, providers may need to consider historical report of patient’s shortness
of breath, documentation of patient’s self-report of distress, and observed clinical signs
of shortness of breath at the time of the visit in which the screening was conducted.
Evidence of shortness of breath being an active problem for the patient could include
(but is not limited to) clinical record documentation noting any of the following: patient’s
self-report of distress or “trouble breathing” from shortness of breath or dyspnea;
documentation of shortness of breath or dyspnea at rest, upon exertion, or at other
times; patient/caregiver report of shortness of breath; observed clinical signs of
distress from shortness of breath; and/or documentation that the symptom is
distressing or limits patient function or quality of life.
On the basis of reports of recent symptoms, current treatment, and patient/family
history, the assessing clinician may determine that shortness of breath is an active
problem, even if shortness of breath does not occur during the assessment visit.
However, there may be situations where an order for Oxygen PRN exists, but the
assessing clinician does not determine shortness of breath to be an active problem for
the patient at the time of the screening. In this situation, the skip pattern is maintained
for J2030C to skip J2040, and the oxygen would not be reported as a treatment for
J2040.
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Chapter 2: Section J
Item-Specific Instructions (continued)
Examples
Situation A - Patient’s clinical record contains the following information:
Clinical note dated 08-12-2021 shows, “patient very drowsy; appears to
be comfortable during visit.”
• HIS Response Selection:
J2030A: Was the patient screened for shortness of breath? Select
response “0, No” and skip to Item N0500, Scheduled Opioid.
Explanation: The documentation in Situation A provides no evidence that the
patient was screened for shortness of breath. Thus, select response “0, No” for
J2030A and skip to Item N0500.
Situation B - Patient’s clinical record contains the following information:
Clinical note dated 08-12-2021 shows, “patient reports no discomfort and is
breathing shallowly but without signs of distress; no concerns about breathing from
patient or family.”
• HIS Response Selection:
J2030A: Was the patient screened for shortness of breath? Select
response “1, Yes.”
J2030B: Date of first screening for shortness of breath: Enter
“08-12-2021.”
J2030C: Did the screening indicate the patient had shortness of breath?
Select response “0, No” and skip to N0500, Scheduled Opioid.
•
•
Explanation: The documentation in Situation B gives evidence that breathing
was screened or assessed. J2030C is reported as “0, No” because the
screening indicated that although the patient was breathing shallowly, there
were no signs of distress or concerns from patient/family.
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Chapter 2: Section J
Examples (continued)
Situations C and D - Patient’s clinical record contains the following information:
Situation C: Clinical note dated 08-12-2021 shows, “patient reports great
difficulty with breathing when walking to the bathroom; breathing is eased after
resting and better if using oxygen when active.”
Situation D: Clinical note dated 08-12-2021 shows, “patient unable to speak;
observed during 20-minute evaluation; respiratory rate 28 with intermittent use of
abdominal breathing; some wheezing on exam but good air movement.”
• HIS Response Selection for Situations C and D:
J2030A: Was the patient screened for shortness of breath? Select
response “1, Yes.”
J2030B: Date of first screening for shortness of breath: Enter
“08-12-2021.”
J2030C: Did the screening indicate the patient had shortness of breath?
Select response “1, Yes.”
Explanation for Situations C and D: In both Situations C and D it is evident
that the clinician used careful questioning and observation to establish the
presence and severity of shortness of breath. Thus, select response “1, Yes”
for J2030A, and continue to J2030B-J2030C, using evidence in the clinical
record to report date and presence or absence of shortness of breath.
Situation E - Patient’s clinical record contains the following information:
Clinical note dated 08-15-2021 reads, “patient reports he is currently not
experiencing any shortness of breath. Patient reports that he does become short of
breath when walking from the bed to the bathroom. Patient reports that when he is
short of breath, shortness of breath is mild to moderate, depending on activity level.”
• HIS Response Selection:
J2030A: Was the patient screened for shortness of breath? Select
response“1, Yes.”
J2030B: Date of first screening for shortness of breath: Enter
“08-15-2021.”
J2030C: Did the screening indicate the patient had shortness of
breath?Select response “1, Yes.”
•
•
Explanation: In Situation E, it is evident the clinician evaluated the patient for
presence and severity of shortness of breath. Thus, select response “1, Yes” for
J2030A and continue to J2030B, entering the date of the screening. J2030C
should be completed based on whether documentation in the clinical record
demonstrates that shortness of breath was an active problem for the patient.
Although the patient was not experiencing shortness of breath at the time of the
screening, clinical record documentation shows that shortness of breath is a
current, active problem for the patient when engaging in certain activities. Thus,
select response“1, Yes” for J2030C.
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Chapter 2: Section J
J2040. Treatment for Shortness of Breath
Enter Code
A. Was treatment for shortness of breath initiated? Select the most
accurate response
0. No Skip to N0500, Scheduled Opioid
1. No, patient declined treatment Skip to N0500, Scheduled
Opioid
2. Yes
B. Date treatment for shortness of breath initiated:
C. Type(s) of treatment for shortness of breath initiated:
Check all that apply
1. Opioids
2. Other medication
3. Oxygen
4. Non-medication
Item-Specific Instructions
Review the clinical record for information regarding treatment for shortness of
breath. Item completion should be based on what is included in the clinical record.
Do not use sources external to the clinical record. Review all response choices
before making a selection.
J2040A: Was treatment for shortness of breath initiated?
• Response 0, No: Select response 0 if there is no documentation that
treatment for shortness of breath was initiated or offered. Skip to Item
N0500, Scheduled Opioid.
• Response 1, No, patient declined treatment: Select response 1 if there is
documentation that the hospice offered treatment for shortness of breath but
the patient or responsible party declined. Skip to Item N0500, Scheduled
Opioid.
• Response 2, Yes: Select response 2 if there is documentation that
treatment for shortness of breath was initiated.
J2040B: Date treatment for shortness of breath initiated
• Enter the date the hospice initiated treatment for shortness of breath.
Use the format Month-Day-Year: MM-DD-YYYY. If the month and/or day
contain only a single digit, enter “0” in the first box of the month and/or day.
For example, November 1, 2021 would be entered as 11-01-2021.
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Chapter 2: Section J
Item-Specific Instructions (continued)
•
For pharmacologic interventions, treatment initiation is defined as the date that
an order was received to initiate or continue a treatment. An order may be
verbal (when permitted) or written; responses for this item should be based on
whichever was used to determine the start of treatment. Enter the date of the
order, irrespective of if/when the first dose was given.
– For orders continued from previous care settings, J2040 should be
completed based on treatments for which the hospice has received orders.
Do not include a “continued” treatment unless the hospice received a new
order to continue the treatment. Once an order is received by the hospice to
continue a treatment, use the date the hospice received the order in
J2040B.
– For comfort kits or pre-printed admission orders, treatment is considered
initiated when the hospice has received the order and there is
documentation that the patient/caregiver was instructed to begin use of the
medication or treatment for the relevant symptom. If the date the hospice
received the order is different than the date the hospice instructed the
patient/caregiver to begin using the treatment/medication, “date treatment
initiated” would be the later date, when both conditions were met (hospice
received order and instructed patient/caregiver to begin use). Proactive
education on medications in a comfort kit in anticipation of symptoms is not
considered “initiation.”
• For non-medication interventions (for example, fans, positioning, patient
education efforts) there will not be any orders; in this case, use the date on
which the hospice first discussed the intervention with the patient/caregiver.
• If the patient received multiple types of treatment for shortness of breath (for
example, oxygen and education about positioning), enter the date that the first
treatment was initiated.
J2040C: Type(s) of treatment for shortness of breath initiated
Check all that apply:
• Check 1, Opioids, if the patient received opioids and there is documentation
that opioids were initiated for shortness of breath.
• Check 2, Other medication, if a non-opioid was initiated for shortness of
breath. Common examples include bronchodilators, inhaled corticosteroids,
oral steroids, diuretics and benzodiazepines. Orders for "other medications"
that have multiple uses (e.g., oral steroids, diuretics, benzodiazepines) must
indicate that the medication was initiated for shortness of breath.
• Check 3, Oxygen, if the patient received oxygen.
• Check 4, Non-medication, if the patient received a non-medication
intervention for shortness of breath other than oxygen. This could include (but
is not limited to) fans, positioning, and education about energy conservation
techniques.
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Chapter 2: Section J
Item-Specific Tips
When reviewing the clinical record for treatments initiated for shortness of breath:
• Include both scheduled and PRN treatments for shortness of breath.
• Include comfort kits or pre-printed admission orders only if the hospice has
received the order and the patient/caregiver has been instructed to begin use
of the medication or treatment for the relevant symptom.
Some treatments have multiple uses (for example, opioids can be used to treat pain
or shortness of breath; relaxation techniques can be used to help with shortness of
breath or anxiety). Only include such treatments in J2040 if the clinical record
indicates that the intended purpose of the treatment is to address the patient’s
shortness of breath.
• Orders that contain multiple purposes for the medication are acceptable as
long as one of the stated purposes is to address shortness of breath.
For J2040C, only include treatments that were initiated on the date listed in J2040B. If
additional treatments for shortness of breath are initiated at a later date, the hospice
should not update J2040C to reflect these additional treatments.
Examples
Situation A - Patient’s clinical record contains the following information:
Clinical documentation dated 08-12-2021 shows, “dyspnea/shortness of breath at
rest, clinical signs indicate patient is short of breath. Patient/family instructed on
energy conservation techniques to alleviate shortness of breath.” Order dated
08-12-2021 shows, “morphine 2-15 mg IV every 4 hours as needed.”
• HIS Response Selection:
J2040A: Was treatment for shortness of breath initiated? Select response
“2, Yes.”
J2040B: Date treatment for shortness of breath initiated: Enter
“08-12-2021.”
J2040C: Type(s) of treatment for shortness of breath initiated: Check “4,
Non-medication” (energy conservation techniques).
• Explanation: Documentation in the clinical record clearly indicates that the
patient was short of breath and that treatment was initiated for shortness of
breath (energy conservation techniques). The morphine treatment listed in the
order list cannot be deemed treatment for shortness of breath because there is
no indication listed in the clinical record that the morphine was prescribed to
treat shortness of breath. To be considered a treatment for shortness of breath,
the order list would need to read “morphine 2-15 mg IV every 4 hours as
needed for shortness of breath” or “as needed for shortness of breath and
pain.”
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Chapter 2: Section J
Examples (continued)
Situation B - Patient’s clinical record contains the following information:
Clinical documentation dated 09-15-2021 shows, “dyspnea/shortness of breath at
rest. Instructed family to keep patient’s head elevated on pillows while patient is in
bed.” Order dated 09-16-2021 shows, “oxygen ordered and scopolamine to dry
respiratory secretions.”
• HIS Response Selection:
J2040A: Was treatment for shortness of breath initiated? Select response
“2, Yes.”
J2040B: Date treatment for shortness of breath initiated: Enter
“09-15-2021.”
J2040C: Type(s) of treatment for shortness of breath initiated: Check “4,
Non-medication” (positioning with pillows).
• Explanation: Documentation in the clinical record clearly indicates that the
patient was short of breath and that more than one treatment was initiated for
shortness of breath. The date that the first treatment for shortness of breath is
initiated (09-15-2021, education about positioning) is the proper date to list in
Item J2040B. For J2040C, only list treatments that were initiated on the date
listed in J2040B.
Situation C – Patient’s clinical record contains the following information:
• Clinical documentation dated 09-15-2021 shows, “patient reports shortness of
breath and is currently using oxygen and nebulizer ordered in previous care
setting.” No orders for oxygen or nebulizer found in the hospice record.
• HIS Response Selection:
J2040A: Was treatment for shortness of breath initiated? Select response
“0, No.” Skip to Item N0500, Scheduled Opioid.
J2040B: Date treatment for shortness of breath initiated: Do not complete.
J2040C: Type(s) of treatment for shortness of breath initiated: Do not
complete.
•
Explanation: Item J2040 should be completed based on treatments for which
the hospice has received orders after assuming responsibility for the care of the
patient. “Initiation” (or continuation) of a treatment from a previous care setting is
defined as the date the hospice received new orders to continue the treatment.
In Situation C, the nebulizer and oxygen cannot be listed as treatments for
shortness of breath in J2040 because there was no evidence in the clinical
record that the hospice received orders to continue these treatments under
hospice care. If new orders for the oxygen and nebulizer were listed in the
hospice clinical record/order list, the treatments could be considered when
completing J2040; in that situation, the hospice would enter the date that the
hospice received the order in J2040B.
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Chapter 2: Section J
Examples (continued)
Situation D - Patient’s clinical record contains the following information:
Clinical documentation dated 09-15-2021 shows, “comfort kit in patient’s home and on
stand-by.” Documentation states, “patient and family were educated on what
medications were in the comfort kit, what symptoms the medications might be used for
(including shortness of breath), and where to store the kit until needed. Patient and
family instructed not to use the medications in the comfort kit until specifically advised
to do so.”
• HIS Response Selection:
J2040A: Was treatment for shortness of breath initiated? Select response
“0, No.” Skip to Item N0500, Scheduled Opioid.
J2040B: Date treatment for shortness of breath initiated: Do not complete.
J2040C: Type(s) of treatment for shortness of breath initiated: Do not
complete.
•
Explanation: Documentation in the clinical record indicates that the comfort kit
included treatments that could be used for shortness of breath, and that the
nurse provided proactive education to the patient/family about the availability of
such treatments. However, documentation in the clinical record does not
indicate that the nurse instructed the patient/family to begin using any of the
treatments for shortness of breath. Thus, for the purposes of completing Item
J2040, treatment for shortness of breath was not initiated; in this situation, the
hospice would enter “0, No” for J2040A and skip J2040B-C. Had the clinical
record included an additional note stating “instructed patient/family to begin
using morphine 2mg PO/SL PRN for shortness of breath,” this would be
sufficient evidence that treatment was initiated, and the hospice would enter “1,
Yes” for J2040A. Date treatment initiated in this situation would be the date on
which the nurse instructed the patient/family to begin using the treatments.
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Chapter 2: Section N
SECTION N: MEDICATIONS
Items in this section of the Hospice Item Set (HIS) gather information on opioids
and bowel regimens.
SECTION N: RATIONALE
Opioids are commonly used in the management of pain and other symptoms.
Constipation is one of the most common opioid-related adverse effects. Most
patients develop some degree of constipation after opioid initiation or dose
increases, and reducing opioid-induced constipation has the potential to reduce
patient discomfort and improve quality of life. Patients do not develop a tolerance to
opioid-induced constipation; clinical guidelines recommend prophylactic bowel
regimens.
N0500. Scheduled Opioid
Enter Code
A. Was a scheduled opioid initiated or continued?
0. No Skip to N0510, PRN Opioid
1. Yes
B. Date scheduled opioid initiated or continued:
Item-Specific Instructions
Review the clinical record for information regarding medications and prescriptions.
Item completion should be based on what is included in the clinical record. Do not
use sources external to the clinical record. Review all response choices before
making a selection.
N0500A: Was a scheduled opioid initiated or continued?
• Response 0, No: Select response 0 if the clinical record indicates that a
regularly scheduled opioid was neither initiated nor continued by the hospice
and skip to Item N0510, PRN Opioid.
• Response 1, Yes: Select response 1 if the clinical record indicates that a
regularly scheduled opioid was initiated or continued from the previous care
setting.
N0500B: Date scheduled opioid initiated or continued
• Enter date scheduled opioid was initiated or continued. Use the format
Month-Day-Year: MM-DD-YYYY. If the month and/or day contain only a
single digit, enter “0” in the first box of the month and/or day. For example,
November 1, 2021 would be entered as 11-01-2021.
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Chapter 2: Section N
Item-Specific Instructions (continued)
•
•
This is the date that the hospice initiated or continued regularly scheduled
opioids. Treatment initiation or continuation is defined as the date that an order
was received. An order may be verbal (when permitted) or written; responses
for this item should be based on whichever was used to determine the start of
treatment. Enter the date of the order, irrespective of if/when the first dose was
given.
– For orders continued from previous care settings, N0500 should be
completed based on scheduled opioids for which the hospice has received
orders. Do not include a continued treatment unless the hospice received a
new order to continue the treatment. Once an order is received by the
hospice to continue a treatment, use the date the hospice received the
order in N0500B.
– For comfort kits or pre-printed admission orders, treatment is considered
initiated when the hospice has received the order and there is
documentation that the patient/caregiver was instructed to begin use of the
medication or treatment. If the date the hospice received the order is
different than the date the hospice instructed the patient/caregiver to begin
using the treatment/medication, “date treatment initiated” would be the later
date, when both conditions were met (hospice received order and instructed
patient/caregiver to begin use). Proactive education on medications in a
comfort kit in anticipation of symptoms is not considered initiation.
If the patient received different types of regularly scheduled opioids in
sequence over time, enter the date that the first type of opioid treatment was
initiated.
Item-Specific Tips
•
Select response “1, Yes” if the clinical record indicates that a regularly scheduled
opioid was initiated for any reason, regardless of symptom.
•
For the purposes of completing Item N0500, an “opioid” includes Schedule II–
Schedule IV opioids, including hydrocodone and tramadol, because of the side
effect profile, which includes constipation.
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Chapter 2: Section N
N0510. PRN Opioid
Enter Code
A. Was a PRN opioid initiated or continued?
0. No Skip to N0520, Bowel Regimen
1. Yes
B. Date PRN opioid initiated or continued:
Item-Specific Instructions
Review the clinical record for information regarding medications and prescriptions.
Item completion should be based on what is included in the clinical record. Do not
use sources external to the clinical record. Review all response choices before
making a selection.
N0510A: Was a PRN opioid initiated or continued?
• Response 0, No: Select response 0 if the clinical record indicates that a
PRN opioid was neither initiated nor continued from the previous care
setting.
• Response 1, Yes: Select response 1 if the clinical record indicates that a
PRN opioid was initiated or continued from the previous care setting.
N0510B: Date PRN opioid initiated or continued
• Enter the date PRN opioid was initiated or continued. Use the format
Month-Day-Year: MM-DD-YYYY. If the month and/or day contain only a
single digit, enter “0” in the first box of the month and/or day. For example,
November 1, 2021 would be entered as 11-01-2021.
• This is the date that the hospice initiated or continued PRN opioids.
Treatment initiation or continuation is defined as the date that an order was
received. An order may be verbal (when permitted) or written; responses
should be based on whichever was used to determine the start of treatment.
Enter the date of the order, irrespective of if/when the first dose was given.
– For orders continued from previous care settings, N0510 should be
completed based on PRN opioids for which the hospice has received
orders. Do not include a continued treatment unless the hospice received
a new order to continue the treatment. Once an order is received by the
hospice to continue a treatment, use the date the hospice received the
order in N0510B.
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Chapter 2: Section N
Item-Specific Instructions (continued)
– For comfort kits or pre-printed admission orders, treatment is considered
initiated when the hospice has received the order and there is
documentation that the patient/caregiver was instructed to begin use of the
medication or treatment. If the date the hospice received the order is
different than the date the hospice instructed the patient/caregiver to begin
using the treatment/medication, “date treatment initiated” would be the later
date, when both conditions were met (hospice received order and instructed
patient/caregiver to begin use). Proactive education on medications in a
comfort kit in anticipation of symptoms is not considered initiation.
•
If the patient received different types of PRN opioids in sequence over time, enter
the date that the first type of opioid treatment was initiated.
Item-Specific Tips
•
Select response “1, Yes” if the clinical record indicates that a PRN opioid was
initiated for any reason, regardless of symptom.
•
For the purposes of completing Item N0510, an “opioid” includes Schedule II–
Schedule IV opioids, including hydrocodone and tramadol, because of the side
effect profile, which includes constipation.
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Chapter 2: Section N
N0520. Bowel Regimen
Complete only if N0500A or N0510A = 1
Enter Code
A. Was a bowel regimen initiated or continued? Select the most
accurate response.
0. No Skip to Z0400, Signature(s) of Person(s) Completing the
Record
1. No, but there is documentation of why a bowel regimen was
not initiated or continued Skip to Z0400, Signature(s) of
Person(s) Completing the Record
2. Yes
B. Date bowel regimen initiated or continued:
Item-Specific Instructions
Review the clinical record for information regarding medications and prescriptions.
Item completion should be based on what is included in the clinical record. Do not
use sources external to the clinical record. Review all response choices before
making a selection.
N0520A: Was a bowel regimen initiated or continued?
Only complete N0520A if N0500A or N0510A = 1. Skip N0520A if the patient is not
on any type of opioid.
• Response 0, No: Select response 0 if the clinical record does not include
documentation that a bowel regimen was initiated or continued from the
previous care setting. Skip to Item Z0400: Signature(s) of Person(s)
Completing the Record.
• Response 1, No, but there is documentation of why a bowel regimen
was not initiated or continued: Select response 1 if the clinical record
indicates that a bowel regimen was not initiated or continued, and includes a
reason why it was not initiated or continued. Skip to Item Z0400:
Signature(s) of Person(s) Completing the Record.
– Documentation why a bowel regimen was not initiated could include
clinical contraindications to a bowel regimen or patient was offered a
bowel regimen but refused treatment.
• Response 2, Yes: Select response 2 if the clinical record includes
documentation that a bowel regimen was initiated or continued from the
previous care setting.
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Chapter 2: Section N
Item-Specific Instructions (continued)
N0520B: Date bowel regimen initiated or continued
• Enter date bowel regimen was initiated or continued. Use the format
Month-Day-Year: MM-DD-YYYY. If the month and/or day contain only a single
digit, enter “0” in the first box of the month and/or day. For example, November
1, 2021 would be entered as 11-01-2021.
• This is the date that the hospice initiated or continued a bowel regimen.
Treatment initiation or continuation is defined as the date that an order was
received. An order may be verbal or written; HIS response selection should be
based on whichever was used to determine the start of treatment. Enter the
date of the order, irrespective of if/when the first dose was given.
– For orders continued from previous care settings, N0520 should be
completed based on bowel regimens for which the hospice has received
orders. Do not include a continued bowel regimen unless the hospice
received a new order to continue the bowel regimen. Once an order is
received by the hospice to continue a bowel regimen, use the date the
hospice received the order in N0520B.
– For comfort kits or pre-printed admission orders, treatment is considered
initiated when the hospice has received the order and there is
documentation that the patient/caregiver was instructed to begin use of the
medication or treatment for the relevant symptom. If the date the hospice
received the order is different than the date the hospice instructed the
patient/caregiver to begin using the treatment/medication, “date treatment
initiated” would be the later date, when both conditions were met (hospice
received order and instructed patient/caregiver to begin use). Proactive
education on medications in a comfort kit in anticipation of symptoms is not
considered initiation.
• For non-pharmacologic bowel regimens, such as prune juice or high-fiber diet,
there may not be any orders; in this case, use the date the hospice nurse or
clinician instructed the patient/family about non-pharmacologic intervention(s).
• If multiple bowel regimens were ordered, enter the date that the first treatment
was initiated.
• In certain instances, the date the bowel regimen was initiated or continued
(listed in N0520B) may precede the date an opioid (scheduled or PRN) was
initiated (listed in N0500B and/or N0510B). This is permissible.
•
The bowel regimen order need not explicitly state it is for the management of
opioid-induced constipation.
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Item-Specific Tips
A bowel regimen may include, but is not limited to the following:
• Laxatives or stool softeners
• High fiber supplements
• Enemas
• Suppositories
• Dietary interventions, such as prune juice or high fiber diet
Clinical record documentation indicating that any of the above bowel regimens were
initiated is sufficient to select response “2, Yes” for N0520A. Orders may be for
regularly scheduled use or for PRN use.
Documentation for why a bowel regimen was not initiated could include clinical
contraindication, including but not limited to the following:
• Bowel obstruction/ileus
• Diarrhea
• No bowel function
• Colostomy/ileostomy
• Nausea/vomiting
• Recent abdominal surgery
• NPO/taking nothing by mouth
Clinical record documentation indicating that any of the above clinical
contraindications (or any other appropriate clinical contraindication) were present is
sufficient to select response “1, No, but there is documentation of why a bowel
regimen was not initiated or continued” for N0520A.
A bowel regimen—or any clinical contraindication to a bowel regimen—may appear in
the patient clinical record as any reference to avoiding constipation, which may not be
linked to opioid prescription.
• In practical terms, this means completing Item N0520 may require review of
other portions of the clinical record (for example, gastrointestinal assessment,
elimination status, bowel function) to find evidence about bowel regimen or
clinical contraindications to bowel regimen.
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Examples
Situation A - Patient’s clinical record contains the following information:
Order dated 08-13-2021 shows, “Oxycodone 10 mg PO every 4 hours, PRN for
pain.” Clinical documentation dated 08-13-2021 shows, “Patient has diarrhea.”
• HIS Response Selection:
N0500A: Was a scheduled opioid initiated or continued? Select response
“0, No.” Skip to N0510, PRN Opioid.
N0510A: Was a PRN opioid initiated or continued? Select response “1,
Yes.”
N0510B: Date PRN opioid initiated or continued: Enter “08-13-2021.”
N0520A: Was a bowel regimen initiated or continued? Select response “1,
No, but there is documentation of why a bowel regimen was not initiated or
continued.” Skip to Item Z0400, Signature(s) of Person(s) Completing the
Record.
• Explanation: Even though the patient is on a PRN opioid, the clinical record
clearly indicates that the patient also has a clinical contraindication (diarrhea).
Thus, select response 1 for N0520A and skip to Item Z0400.
Situation B - Patient’s clinical record contains the following information:
Order dated 07-23-2021 shows, “Morphine 4 mg per hour IV continuous with 2 mg IV
PCA every 15 minutes PRN breakthrough pain.” Clinical documentation dated
07-23-2021 shows, “Last bowel movement 5 days ago. Patient complaining of
abdominal discomfort.” Order dated 07-24-2021 shows, “Polyethylene glycol 17 g PO
with full glass of water once daily.”
• HIS Response Selection:
N0500A: Was a scheduled opioid initiated or continued? Select response
“1, Yes.”
N0500B: Date scheduled opioid initiated or continued: Enter
“07-23-2021.”
N0510A: Was PRN opioid initiated or continued? Select response “1, Yes.”
N0510B: Date PRN opioid initiated or continued: Enter “07-23-2021.”
N0520A: Was a bowel regimen initiated or continued? Select response “2,
Yes.”
N0520B: Date bowel regimen initiated or continued: Enter “07-24-2021.”
• Explanation: Clinical record documentation clearly indicates the patient was
on an opioid (Morphine) and that a bowel regimen was initiated (Polyethylene
glycol).
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Examples (continued)
Situation C - Patient’s clinical record contains the following information:
Clinical documentation dated 08-13-2021 shows, “Last bowel movement 5 days
ago. Patient complaining of abdominal discomfort.” Order dated 08-13-2021 shows,
“Polyethylene glycol 17 g PO with full glass of water once daily.”
• HIS Response Selection:
N0500A: Was a scheduled opioid initiated or continued? Select response
“0, No.” Skip to N0510, PRN Opioid.
N0510A: Was PRN opioid initiated or continued? Select response “0, No.”
Skip to N0520, Bowel Regimen.
N0520A: Was a bowel regimen initiated or continued? Do not complete.
Skip to Item Z0400, Signature(s) of Person(s) Completing the Record.
• Explanation: Even though the patient’s clinical record shows that a bowel
regimen was initiated, because the patient is not on an opioid, do not complete
Item N0520. Skip to Item Z0400, Signature(s) of Person(s) Completing the
Record.
Situation D – Patient’s clinical record contains the following information:
Clinical documentation of initial assessment dated 07-23-20 shows, “comfort kit in
patient’s home and on stand-by. Instructed patient and family on what medications
are in the comfort kit, including pain medication.” Order dated 07-23-2020 shows,
“Polyethylene glycol 17 g PO with full glass of water once daily.” Clinical note dated
7-25-2020 reads, “caregiver called and reported patient was in moderate pain.
Instructed caregiver to open comfort kit and begin giving patient oxycodone 10 mg
every 4 hours as needed for pain.”
• HIS Response Selection:
N0500A: Was a scheduled opioid initiated or continued? Select response
“0, No.” Skip to N0510, PRN opioid.
N0500B: Date scheduled opioid initiated or continued: Do not complete.
N0510A: Was PRN opioid initiated or continued? Select response “1, Yes.”
N0510B: Date PRN opioid initiated or continued: Enter “07-25-2021.”
N0520A: Was a bowel regimen initiated or continued? Select response “2,
Yes.”
N0520B: Date bowel regimen initiated or continued: Enter “07-23-2021.”
• Explanation: For Item N0500A, because there is no scheduled opioid, the
response “0, No” should be selected. For N0510A, the hospice would select
response “1, yes” because clinical record documentation shows there was a
comfort kit including a PRN opioid (oxycodone) for pain and there is
documentation that the nurse instructed the patient/caregiver to begin using the
treatment. For N0510B, use the date on which the nurse instructed the patient/
family to begin using the treatment, which was 07-25-2021. For N0520A, select
“1, Yes.” For N0520B, enter the date of the order for polyethylene glycol.
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HIS Manual
Chapter 2: Section Z
SECTION Z: RECORD ADMINISTRATION
Items in this section contain signatures of individuals completing the Hospice Item Set
(HIS) and the signature of the individual verifying HIS record completion.
SECTION Z: RATIONALE
It is the responsibility of the hospice to ensure the completeness of the HIS.
•
•
•
Section Z is to be used by the provider and should be retained and archived by
the provider in accordance with provider policies and procedures related to
patient information.
Item Z0400 provides a tracking log for the abstracted information contained in the
HIS. The signatures in Z0400 are used to certify that the information the
individual(s) provided is accurate and that the signer was authorized to collect the
information documented on the HIS.
Item Z0500 is used to document the individual responsible for ensuring the HIS is
completed in a timely manner.
Z0400: Signature(s) of Person(s) Completing the Record
I certify that the accompanying information accurately reflects patient
assessment information for this patient and that I collected or coordinated
collection of this information on the dates specified. To the best of my
knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that reporting this
information is used as a basis for payment from federal funds. I further
understand that failure to report such information may lead to a 2 percentage
point reduction in the Fiscal Year payment determination. I also certify that I am
authorized to submit this information by this provider on its behalf.
Signature
Title
Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
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Item-Specific Instructions
Signatures in Z0400 should reflect those hospice staff members who completed
the HIS, which may or may not be the clinician who completed care processes
documented in the clinical record. Signatures may be electronic.
All staff who complete any part of the HIS record shall enter their signature, title,
section, or portion(s) of a section(s) they completed, as well as the date
completed.
• If an individual completes multiple sections of the HIS, that individual can
sign once in Z0400 and indicate which sections they completed in the
“Sections” portion of Z0400.
• One or more staff members can complete items within the same section of
the HIS record. When filling in the information for Z0400, any staff
member who has completed a portion of a section should identify which
item(s) he or she completed within that section.
• If a staff member cannot sign and date Z0400 on the same day that he or
she completed a section or portion of a section of the HIS record, that staff
member should enter the original date of HIS record completion when
signing Z0400.
•
The hospice is responsible for the accuracy of all items on the HIS,
irrespective of how they are completed or auto-populated in the HIS
record.
Read the Attestation Statement carefully. Persons signing Z0400 are certifying
that the information in the HIS record, to the best of their knowledge, most
accurately reflects documentation in the patient’s clinical record.
Item-Specific Tips
• Z0400 is not submitted as part of the HIS record in the QIES ASAP system;
developing internal policies and procedures for completing and archiving
Z0400 is up to the discretion of the hospice.
• This signature-block section (Z0400) is provided for use by the hospice, and
it is suggested that it be retained at the hospice in accordance with policies
and procedures related to patient information.
Z0500. Signature of Person Verifying Record Completion
A. Signature:
B. Date:
Item-Specific Instructions
Sign and date Z0500 after verifying that all items on the record are complete and
that Item Z0400, Signature(s) of Person(s) Completing the Record, contains
attestation for all HIS sections.
•
If for some reason the person verifying record completion is unable to sign
Z0500A on the date the HIS is completed, the staff member should enter in
Z0500B the date when he or she signs Z0500A.
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Chapter 2: Section Z
Item-Specific Tips
•
The signature in Z0500A certifies only that all sections are complete. Persons
completing Z0500 are not certifying the accuracy of portions of the HIS record
that were completed by other hospice staff members.
•
Z0500A is not submitted as part of the HIS record in the Quality Improvement and
Evaluation System (QIES) Assessment Submission and Processing (ASAP)
system; it is at the discretion of the hospice to develop internal policies and
procedures for completing and archiving Z0500A.
•
In the case of a Modification or Inactivation Request, Z0500B should contain the
original date on which the record was completed. Do not change Z0500B unless
the date in Z0500B in the original record was incorrect and the modification
request is to correct the date in Z0500B.
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CHAPTER 3: SUBMISSION AND CORRECTION OF HOSPICE ITEM SET
RECORDS
This chapter details the submission and correction process for Hospice Item Set (HIS)
records and requirements for data submission by hospices for the Hospice Quality
Reporting Program (HQRP) starting July 1, 2014.
3.1
Submitting HIS Records
Hospices must complete and submit required HIS records to the Centers for Medicare &
Medicaid Services’ (CMS’s) Quality Improvement and Evaluation System (QIES)
Assessment Submission and Processing (ASAP) system. Each provider must create
electronic HIS records and submission files using software that creates files that meet
the requirements detailed in the current HIS Data Submission Specifications, available
on the CMS HQRP website at http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-Quality-Reporting/HIS-Technical-Information.html.
Providers must establish communication with the QIES ASAP system to submit a file.
This is accomplished by using specialized communications software installed on their
computer to access the CMS secure wide area network (WAN). Details about how to
obtain WAN software and access are available on the QIES Technical Support Office
(QTSO) website at https://qtso.cms.gov/.
Once communication is established with the QIES ASAP system via the CMS WAN, the
provider can access the hospice welcome page in the QIES ASAP system. This site
allows providers to register for QIES user IDs to submit HIS records and access reports.
Other information, such as user’s guides and bulletins, may also be found on the
hospice welcome page. The technical user guide for HIS submission, the Hospice Item
Set (HIS) Submission User’s Guide, is located on the hospice welcome page and
provides more detailed information about the QIES ASAP system. The technical user
guide is also available on the QTSO website at https://qtso.cms.gov/providers/hospiceproviders/reference-manuals.
When the submission file is received by the QIES ASAP system, the system performs a
series of validation checks to evaluate whether the data submitted meet the required
data specifications. HIS records are edited to verify that clinical responses are within
valid ranges and are consistent with other items in the record, dates are reasonable,
and the submitted record is in the proper order with regard to the records that were
previously accepted by the QIES ASAP system for the same patient. The provider is
notified of the results of this evaluation by error and warning messages on a Final
Validation Report. All error and warning messages are detailed and explained in Section
5 of the Hospice Item Set (HIS) Submission User’s Guide.
3.2
Timeliness Criteria
HIS completion and submission timing requirements have been defined by CMS. The
timing requirements in place encourage appropriate record completion and file
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submission for timely quality reporting. Providers are notified when the timing criteria
have not been met by warnings that appear on the Final Validation Reports.
•
Recommended completion timing for HIS records:
– For HIS-Admission records (A0250 = 1), the Completion Date (Z0500B) is
recommended to be no later than 14 days from the Admission Date (A0220).
Therefore, Z0500B (Completion Date) minus A0220 (Admission Date) is
recommended to be less than or equal to 14 days.
– For HIS-Discharge records (A0250 = 2), the Completion Date (Z0500B) is
recommended to be no later than 7 days from the Discharge Date (A0270).
Therefore, Z0500B (Completion Date) minus A0270 (Discharge Date) is
recommended to be less than or equal to 7 days.
•
Submission timing for HIS records: All HIS records should be submitted
electronically to the QIES ASAP system within 30 days of the Event Date. The
Event Date for a HIS-Admission record is the Admission Date (A0220), and the
Event Date for a HIS-Discharge record is the Discharge Date (A0270).
– For HIS-Admission records (A0250 = 1), the Submission Date may be no later
than 30 days from the Admission Date (A0220). Therefore, the Submission
Date minus the Admission Date (A0220) should be less than or equal to 30
days.
– For HIS-Discharge records (A0250 = 2), the Submission Date may be no later
than 30 days from the Discharge Date (A0270). Therefore, the Submission
Date minus the Discharge Date (A0270) should be less than or equal to 30
days.
3.3
Validation of Records and Files
The QIES ASAP system validation edits are designed to monitor the timeliness and
ensure that the submitted records conform to the HIS Data Submission Specifications.
If submitted HIS records do not meet the edit requirements, the system will provide fatal
error and/or warning messages on the Final Validation Report. The following describes
the validation, storage, and reporting of records in a submission file.
1. Initial Submission Confirmation. For each file submitted, the submitter will
receive an online confirmation that the file was received for processing and
editing by the QIES ASAP system. This confirmation information includes the file
submission number, as well as the date and time the file was received for
processing. Providers should print and maintain a copy of this confirmation.
2. Validation and Editing. Each time a user submits a HIS file to the QIES ASAP
system, three types of validation are performed:
•
Fatal File Errors. The file structure is validated to ensure it follows the
requirements outlined in the HIS Data Submission Specifications provided by
CMS. The file is rejected by the QIES ASAP system if the file structure does
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not meet these requirements. Examples of fatal file errors include the
following:
– The file is not a ZIP file.
– The records in the ZIP file cannot be extracted.
– The file cannot be read.
•
The Submitter Final Validation Report will list any fatal file error(s). Files that
are rejected must be corrected and resubmitted.
•
Fatal Record Errors. If the file structure is acceptable, then each HIS record
in the file is validated individually for fatal record errors. These errors include,
but are not limited to, the following:
– Out-of-range responses (for example, the valid responses for the item are
1, 2, and 3, and the submitted value is 6).
– Inconsistent relationships between items. For example, an inconsistent
date pattern, such as the Patient’s Birth Date (Item A0900) is later than
the Admission Date (Item A0220).
•
Fatal record errors result in rejection of individual records by the QIES ASAP
system. The provider is informed of fatal record error(s) on the Final
Validation Report. Rejected records must be corrected and resubmitted.
•
Warnings (Non-fatal Errors). The record is also validated for warnings (nonfatal errors). Warnings include, but are not limited to, missing or questionable
data of a non-critical nature or item consistency errors of a non-critical nature.
•
Examples of warnings include the following:
– Timing errors
◦
Submission date is more than 30 days after the Admission Date
(A0220) when A0250 = 01.
– Record sequencing errors
◦
A HIS-Admission record is submitted after a previous HIS-Admission
record and there was no HIS-Discharge record submitted in between.
◦
A record is submitted for a patient after a HIS-Discharge record with a
Reason for Discharge (A2115) equal to Expired (01) has been
submitted.
All warnings (non-fatal errors) are reported to the provider in the Final Validation
Report. The provider must evaluate each warning to identify necessary corrective
actions.
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3. Storage to the QIES ASAP System. If there are any fatal record errors, the
record will be rejected and not stored in the QIES ASAP system. If there are no
fatal record errors, the record is stored in the QIES ASAP system, even if the
record has warnings (non-fatal errors).
Detailed information on the validation error and warning messages is available in the
Hospice Item Set (HIS) Submission User’s Guide, which is available on the hospice
welcome page and on the QTSO website at https://qtso.cms.gov/providers/hospiceproviders/reference-manuals.
3.4
HIS Record Correction Policy
The HIS record should be accurate when submitted and accepted into the QIES ASAP
system. When a provider determines that one or more data elements in an accepted
record are inaccurate, the provider must take the necessary steps to correct the
erroneous record (see Section 3.6).
Changes made to the provider’s copy of the HIS record after the record is accepted into
the QIES ASAP system will not be recognized. It is the provider’s responsibility to
correct any errors that exist in a submitted HIS record according to the HIS Record
Correction Policy. This ensures that the information in the QIES ASAP system
accurately reflects the patient’s hospice record. A correction can be submitted for any
accepted record, even if there has been a submission and acceptance of subsequent
records for the patient. Furthermore, it is the provider’s responsibility to ensure the
record is complete and accurate prior to submission to the QIES ASAP system.
Several processes have been put in place to ensure that HIS records are accurate both
at the provider level and in the QIES ASAP system:
•
Software used by the provider to create electronic HIS record files must run all
standard edits as defined in the HIS Data Submission Specifications released by
CMS.
•
Record rejection standards have been implemented in the QIES ASAP system
whereby if a HIS record contains responses that are out of range (for example, a
4 is entered when only 0–3 are allowable responses for an item), or item
responses are inconsistent (for example, a skip pattern is not observed), the
record is rejected. Rejected records are not stored in the QIES ASAP database.
•
If an error is discovered in a record that has been accepted by the QIES ASAP
system, modification or inactivation procedures must be implemented by the
provider to ensure that the QIES ASAP system information is corrected.
The remaining sections of this chapter present the decision processes necessary to
identify the proper correction steps.
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Chapter 3: Submission and Correction
of Hospice Item Set Records
Correcting Errors in HIS Records That Have Not Yet Been Accepted into the
QIES ASAP System
If a HIS record is found to have errors that incorrectly reflect the patient’s information
within the respective record period as established by CMS, then that record must be
corrected. The correction process will depend on the type of error. HIS records that
have not yet been accepted in the QIES ASAP system include records that have been
submitted and rejected, or records that have not been submitted at all. Records that
have been submitted and rejected can usually be corrected and resubmitted without any
special correction procedures because they were never accepted by the QIES ASAP
system. Hospices are responsible for correcting any errors to the record prior to
submission or re-submission of the record to the QIES ASAP system.
3.6
Correcting Errors in HIS Records That Have Been Accepted into the QIES
ASAP System
Hospices should correct any errors necessary to ensure that the information in the QIES
ASAP system accurately reflects the patient’s hospice record. Inaccurate information in
the QIES ASAP system may affect hospice quality reporting results. A HIS record may
be corrected even if subsequent records have been accepted for the patient.
An error identified in a QIES ASAP system HIS record must be corrected. Inaccuracies
can occur for a variety of reasons, such as transcription errors, data entry errors,
software product errors, item response selection errors, or other errors. The following
two processes exist for correcting HIS records that have been accepted into the QIES
ASAP system:
•
Modification Request
•
Inactivation Request
Completion of a Modification Request record will archive the inaccurate HIS record
within the QIES ASAP system and replace the record with the new, corrected record.
Completion of an Inactivation Request will also archive an inaccurate HIS record within
the QIES ASAP system but will not replace the record with the new record.
We recommend that hospices retain a copy of the HIS, along with any corrected
versions, to track what was modified. In addition, it is suggested that the hospice keep a
copy of inactivated records. Copies of HIS records can be maintained in electronic
format. For more details on maintenance of HIS records, see Chapter 1.
Modification Requests
A Modification Request record (A0050 = 2) is used when a HIS record is accepted into
the QIES ASAP system, but the information in the record contains clinical or non-key
demographic errors.
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The Modification Request record (A0050 = 2) is used to correct HIS record items that
are erroneous. However, there are items that cannot be corrected with a Modification
Request; rather, the invalid record must be inactivated with an Inactivation Request
record or manually deleted and a new record submitted to the QIES ASAP system.
Items that cannot be corrected with a Modification Request are:
Record Event Identifiers:
•
A0220: Admission Date (on a HIS-Admission record A0250 = 01)
•
A0250: Reason for Record
•
A0270: Discharge Date (on a HIS-Discharge record A0250 = 09)
Patient Identifier:
•
A0500A: First Name
•
A0500C: Last Name
•
A0600: Social Security Number (SSN)
•
A0800: Gender
•
A0900: Birth Date
Note: To make record event identifier and/or patient identifier corrections, you must
complete an Inactivation Request record for the incorrect record and create a new
record with the correct information. Refer to Inactivation Requests below.
When an error is discovered (except for those items listed in the preceding bullets) in a
HIS record, the provider must submit a Modification Request record (A0050 = 2) to the
QIES ASAP system. When completing a Modification Request record, the Modification
Request record must contain correct values for all items. This means if A0050 = 2, the
provider should proceed to A0100, Facility Provider Numbers, and complete all items in
all other HIS record sections.
Note: In the case of a Modification or Inactivation Request, Z0500B should contain the
original date on which the record was completed. Do not change Z0500B unless the
date in Z0500B in the original record was incorrect and the modification request is to
correct the date in Z0500B.
Note: File creation software varies on how Modification Request records are created.
Please contact your software vendor for specific instructions.
When a Modification Request record (A0050 = 2) is submitted, the QIES ASAP system
will process the record as follows:
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1. The system will attempt to locate the existing record in the QIES ASAP database
for the hospice using specific identifiers:
•
Last name
•
First name
•
SSN
•
Birth date
•
Gender
•
Facility identifier (facility and state code)
•
Event identifiers (for example, the reason for record and admission or
discharge date)
2. If the existing record is not found, the submitted Modification Request record will
be rejected and not accepted in the QIES ASAP system. A fatal error will be
reported to the hospice on the Final Validation Report.
3. If the existing record is found, then the system performs a series of validation
edits to evaluate whether the data submitted meets the required data
specifications. HIS records are edited to verify that clinical responses are within
valid ranges and are consistent with other items in the record, dates are
reasonable, and the submitted record is in the proper order with regard to the
records that were previously accepted by the QIES ASAP system for the same
patient. If there are any fatal errors, the Modification Request record will be
rejected and not accepted in the QIES ASAP system. The fatal error(s) will be
reported to the hospice on the Final Validation Report.
4. If the Modification Request record passes all the edits, it will replace the prior
erroneous record in the QIES ASAP database. The prior erroneous record will be
stored in an archive file within the QIES ASAP database.
Inactivation Requests
An Inactivation Request record (A0050 = 3) must be used when a record has been
accepted into the QIES ASAP system but the corresponding event did not occur, (for
example, a HIS-Discharge record was submitted for a patient, but there was no actual
discharge) or when one or more of the event identifiers or patient identifiers is found to
be in error.
An Inactivation Request (A0050 = 3) must be completed when any of the following items
are inaccurate:
Record Event Identifiers:
•
A0220: Admission Date (on a HIS-Admission record A0250 = 01)
•
A0250: Reason for Record
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•
Chapter 3: Submission and Correction
of Hospice Item Set Records
A0270: Discharge Date (on a HIS-Discharge record A0250 = 09)
Patient Identifier:
•
A0500A: First Name
•
A0500C: Last Name
•
A0600: Social Security Number (SSN)
•
A0800: Gender
•
A0900: Birth Date
Note: Any item in the previous list that was submitted as part of the original record must
also be submitted as part of the Inactivation Request, and values for each item must
match in the erroneous record and the inactivation record. For example, if A0600A,
Social Security Number, was left blank on the original record, it should be left blank on
the inactivation record.
If an Admission Date (A0220), Reason for Record (A0250), or Discharge Date (A0270)
is incorrect, or if one or more patient identifiers are found to be in error, the provider
must inactivate the record in the QIES ASAP system, and then complete and submit a
new HIS record with the correct event and/or patient identifiers and ensure that the
clinical information is accurate.
Note: For an inactivation of a HIS-Admission record, the Discharge Date (A0270) will be
blank.
When an Inactivation Request record (A0050 = 3) is submitted, the QIES ASAP system
will process the record as follows:
1. The system will attempt to locate the existing record in the QIES ASAP database
for this hospice using specific identifiers:
•
Last name
•
First name
•
SSN
•
Birth date
•
Gender
•
Facility identifier (facility and state code)
•
Event identifiers (for example, the reason for record and admission or
discharge date)
2. If the existing record is not found in the QIES ASAP database, the submitted
Inactivation Request record will be rejected, and a fatal error will be reported to
the hospice on the Final Validation Report.
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Chapter 3: Submission and Correction
of Hospice Item Set Records
3. If the existing record is found, the erroneous record will be removed from the
active records in the QIES ASAP database and stored in an archive file within the
QIES ASAP database.
3.7
Special Manual Record Deletion Request
A special Manual Record Deletion Request is only necessary when there has been an
error in a record that has been accepted into the QIES ASAP system that cannot be
corrected with a Modification or Inactivation Request record. There are only two items to
which this applies. A Manual Record Deletion Request must be performed when the
record has the wrong state code (STATE_CD) and/or facility ID (FAC_ID) in the control
items. Control items are items created by the HIS software. These errors most likely
occurred at the time of software installation when initializing the software, and not during
the routine entry of the patient’s administrative or clinical data.
If a QIES ASAP system record has the wrong state code and/or facility ID (control items
STATE_CD and FAC_ID), then the record must be removed without leaving any trace in
the QIES ASAP system. The record must be resubmitted with the correct STATE_CD
and FAC_ID value, when indicated. All data items must be complete and correct on the
newly submitted record.
In the event that this error has occurred, the provider must contact the QTSO Help
Desk by email (iqies@cms.hhs.gov) or telephone (1-877-201-4721) to obtain the
Manual Hospice Item Set Record Correction form. The provider is responsible for
completing the form. The provider must submit the completed form to the QTSO Help
Desk at the address on the form via Certified Mail through the United States Postal
Service (USPS). The QTSO Help Desk will contact CMS for approval upon receipt of
such a request. Upon CMS approval of the manual deletion request, the QTSO Help
Desk will work through the request with the provider.
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APPENDIX A: ACRONYMS AND GLOSSARY
Acronyms
ACA—Patient Protection and Affordable Care Act
CAH—Critical Access Hospital
CCN—CMS Certification Number (also known as Medicare Provider Number)
CMS—Centers for Medicare & Medicaid Services
CNPI—Checklist of Nonverbal Pain Indicators
CPOT—Critical Care Pain Observation Tool
CPR—Cardiopulmonary resuscitation
DD—Developmental Disability
DNI—Do Not Intubate
DNR—Do Not Resuscitate
ESAS—Edmonton Symptom Assessment System
FR—Final Rule
FY—Fiscal Year
HART— Hospice Abstraction Reporting Tool
HIC—Health Insurance Claim
HIS—Hospice Item Set
HQRP—Hospice Quality Reporting Program
ID—Intellectual Disability
IDG—Interdisciplinary Group (also known as Interdisciplinary Team, or IDT)
IRF—Inpatient Rehabilitation Facility or Unit
IV—Intravenous
LTC—Long-Term Care
LTCH—Long-Term Care Hospital
MSAS—Memorial Symptom Assessment Scale
NF—Non-Skilled Nursing Facility
NOS—Not Otherwise Specified
NPI—National Provider Identifier
NPO- Nothing by mouth, “Nil per os”
NQF—National Quality Forum
PACSLAC—Pain Assessment Checklist for Seniors with Limited Ability to Communicate
PAIN-AD—Pain Assessment in Advanced Dementia
PCA—Patient-Controlled Analgesia
PO—By mouth, “Per os”
POLST form—Physician Orders for Life-Sustaining Treatment form
PRN—As needed, “Pro re nata”
QIES ASAP system—Quality Improvement and Evaluation System (QIES) Assessment
and Submission Processing (ASAP) system
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Appendix A-1
HIS Manual
Appendix A
QTSO—QIES Technical Support Office
RRB—Railroad Retirement Board
SNF—Skilled Nursing Facility
SSN—Social Security Number
USPS—United States Postal Service
WAN—Wide Area Network
Definitions
Hospice Item Set (HIS): A standardized set of items intended to capture patient-level
data on each hospice patient admission. HIS items can be used to calculate eight
National Quality Forum (NQF)–endorsed measures, and one non-NQF endorsed
measures. Hospices will submit a HIS-Admission and a HIS-Discharge for each patient
admission on or after July 1, 2014.
Admission Date: The date on which the hospice becomes responsible for the care of
the patient. For Medicare patients, it is the same as the effective date of the hospice
benefit election (or re-election), which may be the first day of hospice care or a later
date, but may be no earlier than the date of the election statement.
Bowel Regimen: If a patient does not have regular bowel movements or has
constipation, a bowel regimen may be used to induce and control bowel movements. A
bowel regimen may include such components as a diet, laxatives, and stool softeners. A
bowel regimen is specific for the patient.
Care Process Item: Care process items appear in Sections F, J, and N of the HISAdmission. In general, HIS care process items direct providers to abstract data from the
hospice clinical record, capturing information about care processes that took place
during the initial or comprehensive assessment periods. Specifically, HIS care process
items capture data about (1) whether or not a care process took place; (2) when the
care process took place; and (3) in some instances, what the results of that care
process were.
Comfort Kit (or pre-printed admission order): A set of medications or treatments
reviewed and approved by medical staff and consistent with nationally recognized and
evidence-based standards, routinely ordered for all patients upon admission to the
hospice (also known as, comfort kits, comfort packs, emergency kits, E kits).
Completion Date: The recommended date that all required information has been
collected and recorded and staff have signed and dated that the record is complete.
This date should represent the date the completion of the item set record has been
verified by the individual authorized to do so. This individual signs and dates Item
Z0500.
Conditions of Participation: The Centers for Medicare & Medicaid Services (CMS)
develops Conditions of Participation (CoPs) that health care organizations must meet in
order to begin and continue participating in the Medicare and Medicaid programs.
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Appendix A-2
HIS Manual
Appendix A
These health and safety standards are the foundation for improving quality and
protecting the health and safety of beneficiaries. Hospice Conditions of Participation can
be found at http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5;node=42%3A3.0.1.1.5.
Discharge Date: The date a patient leaves the hospice. If the patient has expired, it is
the date of death. For live discharges, it is the date the patient revoked the hospice
benefit or the date the hospice discharged the patient for one of the following reasons:
•
Determined to be no longer terminally ill
•
Moved out of the hospice service area
•
Transferred to another hospice
•
For cause
Inactivation Request: Used when a record has been accepted into the Quality
Improvement and Evaluation System (QIES) Assessment and Submission Processing
(ASAP) system but the corresponding event did not occur and when one or more of the
event identifiers and/or patient identifiers is found to be in error.
Manual Deletion Request: Used when a HIS record has been previously submitted
and accepted in the QIES ASAP system but the record was submitted for the wrong
facility. This request will permanently delete all traces of a record from the QIES ASAP
database.
Modification Request: Used when a HIS record has been previously submitted and
accepted in the QIES ASAP system, but the information in the record contains clinical or
non-key demographic errors.
PRN Order: An order prescribed on a patient-by-patient basis for medication or
treatment that is to be used on an “as needed” basis for specific signs and symptoms a
patient is having or may have based on patient-specific conditions or assessment
findings.
Scheduled Order: An order prescribed on a patient-by-patient basis for medication or
treatment that is to be used on a scheduled basis because of patient-specific conditions
or assessment findings. Includes orders to start and to continue scheduled
administration or treatment use.
Submission Date: The date on which the completed record is submitted to the QIES
ASAP system.
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Appendix A-3
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APPENDIX B: CMS HOSPICE QUALITY REPORTING PROGRAM RESOURCES
Websites:
The following links provide more information about the Hospice Quality Reporting
Program (HQRP), and the Hospice Item Set (HIS). The Centers for Medicare &
Medicaid Services (CMS) HQRP website is the official source of information about
HQRP requirements. Providers should bookmark this website and visit it on a regular
basis to make sure they have the most current information pertinent to the HQRP.
1. CMS HQRP Main Page: http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospice-Quality-Reporting/.
•
This website contains additional information about data collection and
submission, HIS Quality Measures, and HIS technical requirements.
2. QIES Technical Support Office (QTSO): Vendors and software developers
should familiarize themselves with this website and review it regularly for
important technical information and updates: https://qtso.cms.gov
•
The HIS Submission User Guide provides more detailed information about
the QIES Assessment Submission and Processing (ASAP) system and is
available at https://qtso.cms.gov/providers/hospice-providers/referencemanuals.
•
Vendors should register at https://qtso.cms.gov/vendors/hospicevendors/training to receive important announcements.
3. National Quality Forum (NQF): To read more about the eight NQF-endorsed
measures, visit the NQF website:
http://www.qualityforum.org/Home.aspx.
4. The HQRP consists of two components, the HIS and the Consumer Assessment
of Healthcare Providers and Systems (CAHPS®) Hospice Survey— HQRP = HIS
+ CAHPS®. This manual only includes guidance specific to the HIS. For details
about participation requirements and CAHPS® Hospice Survey implementation,
visit the CAHPS® Hospice Survey webpage:
https://www.hospicecahpssurvey.org/
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Appendix B-1
HIS Manual
Appendix B
Help Desks:
1. Quality Help Desk: For assistance with questions related to reporting
requirements, quality measures, and reporting deadlines.
•
E-mail: HospiceQualityQuestions@cms.hhs.gov
2. General QTSO Help Desk: For assistance regarding technical
questions.
•
Phone: 1-877-201-4721
•
E-mail: iqies@cms.hhs.gov
Listservs:
1. Open Door Forum (ODF) listserv: CMS regularly holds Open Door Forums in
which it makes announcements pertinent to various programs/care settings.
Open Door Forums are also an opportunity for live dialogue between CMS and
the provider community. The specific Open Door Forum pertinent to the HQRP is
the "Home Health, Hospice, and Durable Medical Equipment Open Door Forum."
Use the link to sign up:
https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCM
S_502
2. MLN Connects® Provider eNews Listserv: CMS sends out a weekly eNewsletter, which contains information pertinent to various Medicare programs
and care settings. Use the link to sign up: http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive.html
V3.00 Effective February 16, 2021
Appendix B-2
APPENDIX C: QUALITY MEASURE LOGICAL SPECIFICATIONS
Logical specifications for HIS-based quality measures can be found in “Hospice Quality
Reporting Program: Specifications for the Hospice Item Set-Based Quality Measures”,
available on the “Current Measures” portion of the CMS HQRP website:
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Hospice-Quality-Reporting/Current-Measures.html.
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Appendix C-1
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APPENDIX D(a): HOSPICE ITEM SET—ADMISSION
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 09381153. The time required to complete this information collection is estimated to
average 14 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.
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Appendix D(a)-1
Hospice Item Set - Admission
Section A
Administrative Information
A0050. Type of Record
Enter Code
1. Add new record
2. Modify existing record
3. Inactivate existing record
A0100. Facility Provider Numbers. Enter code in boxes provided.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
A0205. Site of Service at Admission
Enter Code
01. Hospice in patient's home/residence
02. Hospice in Assisted Living facility
03. Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility
(NF)
04. Hospice provided in a Skilled Nursing Facility (SNF)
05. Hospice provided in Inpatient Hospital
06. Hospice provided in Inpatient Hospice Facility
07. Hospice provided in Long Term Care Hospital (LTCH)
08. Hospice in Inpatient Psychiatric Facility
09. Hospice provided in a place not otherwise specified (NOS)
10. Hospice home care provided in a hospice facility
A0220. Admission Date
Month
Day
Year
Month
Day
Year
A0245. Date Initial Nursing Assessment Initiated
A0250. Reason for Record
Enter Code
01. Admission
09. Discharge
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Appendix D(a)-2
HIS Manual
Appendix D(a)
Section A
Administrative Information
A0500. Legal Name of Patient
A. First name:
B. Middle initial:
C. Last name:
D. Suffix:
A0550. Patient ZIP Code. Enter code in boxes provided.
Patient ZIP Code:
-
A0600. Social Security and Medicare Numbers
A. Social Security Number:
-
-
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid Recipient
A0800. Gender
Enter Code
1. Male
2. Female
A0900. Birth Date
Month
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Day
Year
Appendix D(a)-3
HIS Manual
Appendix D(a)
Section A
Administrative Information
A1000. Race/Ethnicity
Check all that apply
A. American Indian or Alaska Native
B.
C.
D.
E.
F.
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
A1400. Payor Information
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care)
G. Other government (e.g., TRICARE, VA, etc.)
H. Private Insurance/Medigap
I. Private managed care
J. Self-pay
K. No payor source
X. Unknown
Y. Other
A1802. Admitted From. Immediately preceding this admission, where was the patient?
Enter Code
01. Community residential setting (e.g., private home/apt., board/care, assisted living,
group home, adult foster care)
02. Long-term care facility
03. Skilled Nursing Facility (SNF)
04. Hospital emergency department
05. Short-stay acute hospital
06. Long-term care hospital (LTCH)
07. Inpatient rehabilitation facility or unit (IRF)
08. Psychiatric hospital or unit
09. ID/DD Facility
10. Hospice
99. None of the Above
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Appendix D(a)-4
HIS Manual
Appendix D(a)
Section F
Preferences
F2000. CPR Preference
Enter Code
A. Was the patient/responsible party asked about preference regarding the use of
cardiopulmonary resuscitation (CPR)? - Select the most accurate response
0. No Skip to F2100, Other Life-Sustaining Treatment Preferences
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about preference regarding the
use of CPR:
Month
Day
Year
F2100. Other Life-Sustaining Treatment Preferences
Enter Code
A. Was the patient/responsible party asked about preferences regarding life-sustaining
treatments other than CPR? - Select the most accurate response
0. No Skip to F2200, Hospitalization Preference
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about preferences regarding lifesustaining treatments other than CPR:
Month
Day
F2200. Hospitalization Preference
Enter Code
Year
A. Was the patient/responsible party asked about preference regarding
hospitalization? - Select the most accurate response
0. No Skip to F3000, Spiritual/Existential Concerns
1. Yes, and discussion occurred
2. Yes, but the patient/responsible party refused to discuss
B. Date the patient/responsible party was first asked about preference regarding
hospitalization:
Month
Day
F3000. Spiritual/Existential Concerns
Enter Code
Year
A. Was the patient and/or caregiver asked about spiritual/existential concerns? - Select
the most accurate response
0. No Skip to I0010, Principal Diagnosis
1. Yes, and discussion occurred
2. Yes, but the patient and/or caregiver refused to discuss
B. Date the patient and/or caregiver was first asked about spiritual/existential
concerns:
Month
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Day
Year
Appendix D(a)-5
HIS Manual
Section I
Appendix D(a)
Active Diagnoses
I0010. Principal Diagnosis
Enter Code
01. Cancer
02. Dementia/Alzheimer’s
99. None of the above
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Appendix D(a)-6
HIS Manual
Appendix D(a)
Section J
Health Conditions
Pain
J0900. Pain Screening
Enter Code
A. Was the patient screened for pain?
0. No Skip to J0905, Pain Active Problem
1. Yes
B. Date of first screening for pain:
Enter Code
Enter Code
Month
Day
C. The patient’s pain severity was:
0. None
1. Mild
2. Moderate
3. Severe
9. Pain not rated
Year
D. Type of standardized pain tool used:
1. Numeric
2. Verbal descriptor
3. Patient visual
4. Staff observation
9. No standardized tool used
J0905. Pain Active Problem
Enter Code
Is pain an active problem for the patient?
0. No Skip to J2030, Screening for Shortness of Breath
1. Yes
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Appendix D(a)-7
HIS Manual
Appendix D(a)
Section J
Health Conditions
J0910. Comprehensive Pain Assessment
Enter Code
A. Was a comprehensive pain assessment done?
0. No Skip to J2030, Screening for Shortness of Breath
1. Yes
B. Date of comprehensive pain assessment:
Month
Day
Year
C. Comprehensive pain assessment included:
Check all that apply
1. Location
2. Severity
3. Character
4. Duration
5. Frequency
6. What relieves/worsens pain
7. Effect on function or quality of life
9. None of the above
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Appendix D(a)-8
HIS Manual
Appendix D(a)
Section J
Health Conditions
Respiratory Status
J2030. Screening for Shortness of Breath
Enter Code
A. Was the patient screened for shortness of breath?
0. No Skip to N0500, Scheduled Opioid
1. Yes
B. Date of first screening for shortness of breath:
Enter Code
Month
Day
Year
C. Did the screening indicate the patient had shortness of breath?
0. No Skip to N0500, Scheduled Opioid
1. Yes
J2040. Treatment for Shortness of Breath
Enter Code
A. Was treatment for shortness of breath initiated? - Select the most accurate response
0. No Skip to N0500, Scheduled Opioid
1. No, patient declined treatment Skip to N0500, Scheduled Opioid
2. Yes
B. Date treatment for shortness of breath initiated:
Month
Day
Year
C. Type(s) of treatment for shortness of breath initiated:
Check all that apply
1. Opioids
2. Other medication
3. Oxygen
4. Non-medication
V3.00 Effective February 16, 2021
Appendix D(a)-9
HIS Manual
Appendix D(a)
Section N
Medications
N0500. Scheduled Opioid
Enter Code
A. Was a scheduled opioid initiated or continued?
0. No Skip to N0510, PRN Opioid
1. Yes
B. Date scheduled opioid initiated or continued:
Month
N0510. PRN Opioid
Enter Code
Day
Year
A. Was a PRN opioid initiated or continued?
0. No Skip to N0520, Bowel Regimen
1. Yes
B. Date PRN opioid initiated or continued:
Month
Day
N0520. Bowel Regimen
Complete only if N0500A or N0510A = 1
Enter Code
Year
A. Was a bowel regimen initiated or continued? - Select the most accurate response
0. No Skip to Z0400, Signature(s) of Person(s) Completing the Record
1. No, but there is documentation of why a bowel regimen was not initiated or
continued Skip to Z0400, Signature(s) of Person(s) Completing the Record
2. Yes
B. Date bowel regimen initiated or continued:
Month
V3.00 Effective February 16, 2021
Day
Year
Appendix D(a)-10
HIS Manual
Section Z
Appendix D(a)
Record Administration
Z0400. Signature(s) of Person(s) Completing the Record
I certify that the accompanying information accurately reflects patient assessment
information for this patient and that I collected or coordinated collection of this information on
the dates specified. To the best of my knowledge, this information was collected in accordance
with applicable Medicare and Medicaid requirements. I understand that reporting this
information is used as a basis for payment from federal funds. I further understand that failure to
report such information may lead to a 2 percentage point reduction in the Fiscal Year payment
determination. I also certify that I am authorized to submit this information by this provider on its
behalf.
Signature
Title
Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Record Completion
A. Signature:
B. Date:
___________________________________________
Month
V3.00 Effective February 16, 2021
Day
Year
Appendix D(a)-11
APPENDIX D(b): HOSPICE ITEM SET—DISCHARGE
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 09381153. The time required to complete this information collection is estimated to
average 9 minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop
C4-26-05, Baltimore, Maryland 21244-1850.
V3.00 Effective February 16, 2021
Appendix D(b)-1
HIS Manual
Appendix D(b)
Hospice Item Set – Discharge
Section A
Administrative Information
A0050. Type of Record
Enter Code
1. Add new record
2. Modify existing record
3. Inactivate existing record
A0100. Facility Provider Numbers. Enter code in boxes provided.
A. National Provider Identifier (NPI):
B. CMS Certification Number (CCN):
A0220. Admission Date
Month
A0250. Reason for Record
Enter Code
Day
Year
Day
Year
01. Admission
09. Discharge
A0270. Discharge Date
Month
A0500. Legal Name of Patient
A. First name:
B. Middle initial:
C. Last name:
D. Suffix:
V3.00 Effective February 16, 2021
Appendix D(b)-2
HIS Manual
Appendix D(b)
Section A
Administrative Information
A0600. Social Security and Medicare Numbers
A. Social Security Number:
-
-
B. Medicare number (or comparable railroad insurance number):
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid Recipient
A0800. Gender
Enter Code
1. Male
2. Female
A0900. Birth Date
Month
Day
A2115. Reason for Discharge
Enter Code
Year
01. Expired
02. Revoked
03. No longer terminally ill
04. Moved out of hospice service area
05. Transferred to another hospice
06. Discharged for cause
V3.00 Effective February 16, 2021
Appendix D(b)-3
HIS Manual
Section Z
Appendix D(b)
Record Administration
Z0400. Signature(s) of Person(s) Completing the Record
I certify that the accompanying information accurately reflects patient assessment
information for this patient and that I collected or coordinated collection of this information on
the dates specified. To the best of my knowledge, this information was collected in accordance
with applicable Medicare and Medicaid requirements. I understand that reporting this
information is used as a basis for payment from federal funds. I further understand that failure to
report such information may lead to a 2 percentage point reduction in the Fiscal Year payment
determination. I also certify that I am authorized to submit this information by this provider on its
behalf.
Signature
Title
Sections
Date Section
Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Record Completion
A. Signature:
B. Date:
________________________________________________
Month
V3.00 Effective February 16, 2021
Day
Year
Appendix D(b)-5
| File Type | application/pdf |
| File Title | HIS Manual |
| Subject | Guidance Manual for Completion of the Hospice Item Set (HIS) |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2021-02-24 |
| File Created | 2018-11-12 |