US · guidance
CMS Pub. 100-11, ch. 10, § 30.9
HOS-M Instrument
The Medicare HOS-M contains the following core components:
• The Veterans RAND 12 Item Health Survey (VR-12);
• Activity of Daily Living (ADL) items.
The HOS-M instrument is a shorter, modified version of the Medicare Health Outcomes
Survey and contains 6 ADL items as the core items used to calculate the frailty
adjustment factor for payment purposes. The survey also includes 12 physical and mental
health status questions from the VR-12. In addition, the HOS-M includes questions about
the following: lifting or carrying objects as heavy as 10 pounds; walking a quarter mile;
health or physical problems interfering with daily activities, receiving help with ADLs;
physical and emotional health compared to one year ago; memory loss; urinary
incontinence; and a question on whether the survey was self-completed or completed by a
proxy. If the participant received assistance completing the survey, the respondent was
asked information about the proxy respondent.
History
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
e0b4bcbf23c5191b318645f0561d51ea6b7a412e931ad4ca50bd27469232962e
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