CMS-10390 HOPE Update Visit

HOPE Update Visit (HUV)

OMB Control Number XXXX-XXXX
Expiration XX/XX/XXXX

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. HOPE is a patient assessment instrument that
intends to collect data during a hospice patient’s stay. Data collected using this instrument will be used to
measure the quality of care provided by a hospice provider. The valid OMB control number for this information
collection is XXXX-XXXX. Submission of this data is required by Section 1814(i)(5) of the Social Security Act.
The time required to complete this data collection is estimated to average XX minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and complete and
review the data collected. Submitted patient-level data will remain confidential and is protected from public
dissemination in accordance with the Privacy Act of 1974, as amended. 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.
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will
not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Jermama Keys, National Coordinator, Hospice Quality Reporting Program Centers
for Medicare & Medicaid Services, at Jermama.Keys@cms.hhs.gov.

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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HOPE Update Visit TIMEPOINT - HOPE Version 1
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
A. National Provider Identifier (NPI):

B.

CMS Certification Number (CCN):

A0220. Admission Date

 Month    Day      Year
A0250. Reason for Record
Enter Code

1.  Admission (ADM)
2.  HOPE Update Visit 1 (HUV1)
3.  HOPE Update Visit 2 (HUV2)
9.  Discharge (DC)

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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A0500. Legal Name of Patient
A. First name:

B.

Middle initial:

C.

Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers
A. Social Security Number:

-

B.

-

Medicare 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      Year
A1400. Payer Information
↓  Check all existing payer sources that apply at the time of this assessment
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 payer source
X. Unknown
Y. Other
HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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Section J

Health Conditions

J0050. Death is Imminent
Enter Code

At the time of this assessment and based on your clinical assessment, does the patient appear to have a life
expectancy of 3 days or less?
0. No
1. Yes

J2050. Symptom Impact Screening
Enter Code

A. Was a symptom impact screening completed?
0. No — Skip to M1190, Skin Conditions
1. Yes
B.

Date of symptom impact screening:

Month     Day      Year

J2051. Symptom Impact
Over the past 2 days, how has the patient been affected by each of the following symptoms? Base this on your clinical
assessment (including input from patient and/or caregiver). Symptoms may impact multiple patient activities including, but not
limited to, sleep, concentration, day to day activities, or ability to interact with others.
Coding:
0. Not at all – symptom does not affect the patient, including symptoms well-controlled with current treatment
1. Slight
2. Moderate
3. Severe
9. Not applicable (the patient is not experiencing the symptom)
Enter Code
↓
A. Pain
B. Shortness of breath
C. Anxiety
D. Nausea
E. Vomiting
F. Diarrhea
G. Constipation
H. Agitation

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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J2052. Symptom Follow-up Visit (SFV) (complete only if any response to J2051 Symptom Impact = 2. Moderate or 3. Severe)

Enter Code

An in-person Symptom Follow-up Visit (SFV) should occur within 2 calendar days as a follow-up for any moderate
or severe pain or non-pain symptom identified during Symptom Impact assessment at Admission or HOPE Update
Visit (HUV).
A.

B.

Was an in-person SFV completed?
0. No — Skip to J2052C. Reason SFV Not Completed.
1. Yes
Date of in-person SFV:

Enter Code

Month    Day       Year
C.

Reason SFV Not Completed.
1.
2.
3.
9.

Patient and/or caregiver declined an in-person visit.
Patient unavailable (e.g., in ED, hospital, travel outside of service area, expired).
Attempts to contact patient and/or caregiver were unsuccessful.
None of the above

J2053. SFV Symptom Impact
Since the last Symptom Impact assessment was completed, how has the patient been affected by each of the following
symptoms? Base this on your clinical assessment (including input from patient and/or caregiver). Symptoms may impact multiple
patient activities including, but not limited to, sleep, concentration, day to day activities, or ability to interact with others.
Coding:
0. Not at all – symptom does not affect the patient, including symptoms well-controlled with current treatment
1. Slight
2. Moderate
3. Severe
9. Not applicable (the patient is not experiencing the symptom)
Enter Code
↓
A. Pain
B. Shortness of breath
C. Anxiety
D. Nausea
E. Vomiting
F. Diarrhea
G. Constipation
H. Agitation

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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Section M

Skin Conditions

M1190. Skin Conditions
Enter Code

Does the patient have one or more skin conditions?
0. No - Skip to N0500, Scheduled Opioid
1. Yes

M1195. Types of Skin Conditions
Indicate which following skin conditions were identified at the time of this assessment.
↓ Check all that apply
A. Diabetic foot ulcer(s)
B. Open lesion(s) other than ulcers, rash, or skin tear (cancer lesions)
C. Pressure Ulcer(s)/Injuries
D. Rash(es)
E. Skin tear(s)
F. Surgical wound(s)
G. Ulcers other than diabetic or pressure ulcers (e.g., venous stasis ulcer, Kennedy ulcer)
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration,
drainage)
Z. None of the above were present
M1200. Skin and Ulcer/Injury Treatments
Indicate the interventions or treatments in place at the time of this assessment.
↓ Check all that apply
A. Pressure reducing device for chair
B. Pressure reducing device for bed
C. Turning/repositioning program
D. Nutrition or hydration intervention to manage skin problems
E. Pressure ulcer/injury care
F.  Surgical wound care
G. Application of nonsurgical dressings (with or without topical medications) other than to feet
H. Application of ointments/medications other than to feet
I. Application of dressings to feet (with or without topical medications)
J. Incontinence Management
Z. None of the above were provided

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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Section N

Medications

N0500. Scheduled Opioid
Enter Code

Was a scheduled opioid initiated or continued?

A.

0.
1.
B.

No — Skip to N0510, PRN Opioid
Yes

Date scheduled opioid initiated or continued:

Month    Day      Year

N0510. PRN Opioid
Enter Code

A. Was PRN opioid initiated or continued?
0.
1.
B.

No — Skip to N0520, Bowel Regimen
Yes

Date PRN opioid initiated or continued:

Month    Day      Year

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.
1.
2.

B.

No — Skip to Z0400. Signature(s) of Person(s) Completing the Record
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
Yes

Date bowel regimen initiated or continued:

Month    Day      Year

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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Section Z

Assessment Administration

Z0350. Date Assessment was Completed

Month    Day      Year

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 payment reduction in
the Fiscal Year payment determination. I also certify that I am authorized to submit this information by this provider on its behalf.
Signatures

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.

___________________________________________________
B.

Signature

Date

Month    Day      Year

HOPE Update Visit (HUV)
Centers for Medicare & Medicaid Services

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