* = Required Information

Follow M0 number in sequence unless otherwise directed. = Quality Indicator DATE
REASON FOR ASSESSMENT:
Recertification Other Follow-up
TIME IN TIME OUT
This Patient Tracking Information must be filled out at start of care and per organizational policy.
It is to be maintained as part of the clinical record.
(M0010) CMS Certification Number:      (Locator #5)
Branch Identification   (M0014) Branch State:
(M0016) Branch ID Number:
(M0018) National Provider Indentifier(NPI) for the attending physician who has signed the plan of care:
UK - Unknown or Not Available
Phone: (Locator #24)
Name: (Locator #24)
(First) (MI)
(Last) (Suffix)
Address: (Street/Apt. No.) (Locator #24)
City: (Locator #24)
State: (Locator #24) Zip Code: (Locator #24)

Secondary Referring Physician I.D.#:
Phone:
Name:
(First) (MI)
(Last) (Suffix)

(M0020) Patient ID Number:     (Locator #4)
Medical Record Number if different than M0020
(M0030) Start of Care Date:     (Locator #2)
  month    day    year
(M0032) Resumption of Care Date:     
NA - Not Applicable month    day    year
(M0042) Patient Name:    (Locator #6)
(First) (MI)
(Last) (Suffix)
Patient Phone:
Patient Address:     (Locator #6)
(Street/Apt. No.)
(City)
(M0050) Patient State of Residence:    (Locator #6)
(M0060) Patient Zip Code:    (Locator #6)
(M0063) Medicare Number: NA - No Medicare
(Including suffix)
(M0064) Social Security Number: UK - Unknown or Not Available
--  
(M0064) Medicaid Number: NA - No Medicaid
 
(M0066) Birth Date:          (Locator #8)
  month    day    year
Patient's HI Claim No.:      (Locator #1)
1 - Same as M0063 2 - Same as M0065
3 - Other
(M0069) Gender:    (Locator #9) 1 - Male2 - Female
Emergency Triage Code:
DNR Order:
Obtained Requested
CLINICAL RECORD ITEMS
(M0080) Discipline Person Completing Assessment:
1-RN 2-PT
3-SLP/ST 4-OT
Type of Visit:
Skilled Supervisory only
Skilled & Supervisory Other
 
(M0090) Date Assessment Completed:
(M0100) This Assessment is Currently Being Completed for the Following Reason: Follow-Up
4 - Recertification (follow-up) reassessment     [Go to M0110]
5 - Other follow-up     [Go to M0110]
     Complete M0032 information
Certification Period:       (Locator #3)
  From   To  
(M0110) Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequense of adjacent Medicare home health payment episodes?
1 - Early
2 - Later
UK - Unknown
NA - Not Applicable: No Medicare case mix group to be defined by this assessment.
*Early Episode is first or second episode in a sequence of adjacent episodes. Later is the third episode and beyond in sequence of adjacent episodes. Adjacent episodes are separated by 60 days or fewer between episodes.
PATIENT NAME - Last, First, Middle Initial
ID#

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