October 2012 Item Matrix 12-09-2011

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD & EVALUATION DATA SET, ITEM MATRIX, Version 1.0, January 2012

Unplanned Discharge

Expired

Admission

Planned Discharge

Unplanned Discharge

Expired

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

A0055

Correction Number

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

A0100A

Facility National Provider Identifier (NPI)

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

A0100B
A0100C

Facility CMS Certification Number (CCN)
State provider number

X
X

X
X

X
X

X
X

X

X

X

X

X

X

X

X Required administrative item for data submission

A0200

Type of provider

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

A0210

Assessment Reference Date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

A0220

Admission Date

X

X

X

X

X

X

X

X

X

X

X

A0250
A0270
A0500A
A0500B

Reason for Assessment
Discharge Date (Expired Date for Expired form)
Patient first name
Patient middle initial

X

X
X
X
X

X
X
X
X

X
X

X
X
X

X
X
X

X
X
X

X

X
X

X
X
X
X

X

X
X
X

X
X
X

X Required administrative item for data submission
Part of PU denominator calculation, Required
X administrative item
X Required administrative item
X Required administrative item

A0500C
A0500D
A0600A

Patient last name
Patient name suffix
Social Security Number

X
X
X

X
X
X

X
X
X

X
X
X

X

X

X

X

X

X

X

X Required administrative item

X

X

X

X

X

X

X

X Required administrative item

A0600B
A0700

Patient Medicare/railroad insurance number
Patient Medicaid number

X
X

X
X

X
X

X
X

A0800

Gender

X

X

X

X

X

X

X

A0900
A1000A
A1000B
A1000C
A1000D
A1000E
A1000F
A1050

Birth date
Race/Ethnicity: American Indian or Alaska Native
Race/Ethnicity: Asian
Race/Ethnicity: Black or African American
Race/Ethnicity: Hispanic or Latino
Race/Ethnicity: Native Hawaiian/Pacific Islander
Race/Ethnicity: White
Highest degree/level of school

X
X
X
X
X
X
X
X

X
X
X
X
X
X
X

X
X
X
X
X
X
X

X
X
X
X
X
X
X

X

X

X

X Required administrative item, Gender Disparities
Required administrative item (year only), Age-based
X disparities

X

X

X

X

X

X

Expired

Planned Discharge

Type of Record

X

Unplanned Discharge

Admission

A0050

Planned Discharge

Description

Admission

Item No.

Expired

Administrative
Items Required
for Data
Submission

Unplanned Discharge

Items Required
to calculate for
PU (Short-Stay)
Measure

Planned Discharge

Mandatory Items
for Oct 2012

Admission

Included
on Oct 2012
LTCH Item Set

X

Rationale for Inclusion as a Mandatory Item for
January 2012

1

Planned Discharge

Unplanned Discharge

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

A1400K

Payer Information: Current Payment Source(s): Self-pay
Payer Information: Current Payment Source(s): No Payor
Source

X

X

X

X

X

X

X

X

X

X

X

A1400X

Payer Information: Current Payment Source(s): Unknown

X

X

X

X

X

X

X

X

X

X

X

A1400Y
A1800
A1810A

Payer Information: Current Payment Source(s): Other
Admitted from
Past 2 months: Short-stay acute hospital (IPPS)
Past 2 months: Community residential setting (private home,
assisted living, etc.)
Past 2 months: Long-term care facility
Past 2 months: Skilled nursing facility
Past 2 months: Hospital emergency department
Past 2 months: Long-term care hospital
Past 2 months: Inpatient rehabilitation hospital or unit
Past 2 months: Home health agency

X
X
X

X

X

X

X

X

X

X

X

X

X

A1400C
A1400D
A1400E
A1400F
A1400G
A1400H
A1400I
A1400J

A1810B
A1810C
A1810D
A1810E
A1810F
A1810G
A1810H

Payer Information: Current Payment Source(s): Title programs
(e.g., III, V, or XX)
Payer Information: Current Payment Source(s): Other
government (TRICARE, VA)
Payer Information: Current Payment Source(s):Private
insurance/Medigap
Payer Information: Current Payment Source(s): Private
managed care

Expired

Admission

X

Expired

X

A1400B

Unplanned Discharge

Expired

X

Planned Discharge

Unplanned Discharge

X

A1400A

Description
Does the Patient need or want an interpreter
Preferred language
Marital status
Lifetime occupation(s)
Payer Information: Current Payment Source(s): Medicare
(traditional FFS)
Payer Information: Current Payment Source(s): Medicare
(managed care, Part C, Medicare Advantage)
Payer Information: Current Payment Source(s): Medicaid
(traditional FFS)
Payer Information: Current Payment Source(s): Medicaid
(managed care)
Payer Information: Current Payment Source(s): Workers'
compensation

Admission

Planned Discharge

X

Item No.
A1100A
A1100B
A1200
A1300C

Admission

Admission

Administrative
Items Required
for Data
Submission

Expired

Items Required
to calculate for
PU (Short-Stay)
Measure

Unplanned Discharge

Mandatory Items
for Oct 2012

Planned Discharge

Included
on Oct 2012
LTCH Item Set

Rationale for Inclusion as a Mandatory Item for
January 2012

X
X
X
X
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes
Required administrative item, Type of Insurance
X affects Quality Outcomes

X
X
X
X
X
X
X
2

I0900
I2900
I5600
K0200A
K0200B
M0210
M0300A
M0300B1
M0300B2
M0300B3
M0300C1
M0300C2
M0300D1
M0300D2

M0300E1

Active diagnosis: Malnutrition (protein or calorie) or at risk for
malnutrition
Height (in inches)
Weight (in pounds)
Unhealed pressure ulcer(s)
Stage 1: Number of stage 1 pressure ulcers
Stage 2: Number of stage 2 pressure ulcers
Stage 2: Number of these stage 2 pressure ulcers that were
present upon admission/reentry

X
X
X
X
X
X

Stage 2: Date of oldest Stage 2 pressure ulcer
Stage 3: Number of stage 3 pressure ulcers
Stage 3: Number of these stage 3 pressure ulcers that were
present upon admission/reentry
Stage 4: Number of stage 4 pressure ulcers
Stage 4: Number of these stage 4 pressure ulcers that were
present upon admission/reentry
Unstageable - Non-removable dressing: Number of
unstageable pressure ulcers due to non-removable
dressing/device

X

X

X

X

X
X
X
X

X
X
X
X

X
X

X
X

X
X

X
X

X
X

X
X

X
X

Part of covariate calculation for PU measure
Part of covariate calculation for PU measure

X
X
X
X
X
X

X
X
X
X
X
X

X
X
X
X
X

X
X
X
X
X

X
X
X
X
X

X
X

X
X

X
X

X

X

X

X

X

X

X

X

X

X
X

X
X

X
X

X

X

X

X

X

X

Part of Skin Conditions Section
Part of numerator calculation for PU measure

X
X

X
X

X
X

X
X

X
X

X
X

X

X

X

Part of Skin Conditions Section
Part of numerator calculation for PU measure

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of Skin Conditions Section

Expired

X
X

Unplanned Discharge

X
X

Planned Discharge

X
X
X
X

Critical to assess patient condition, risk factor for PU
for LTCH patient population
Part of covariate calculation for PU measure
Part of covariate calculation for PU measure
Part of covariate calculation for PU measure
Part of covariate calculation for PU measure

Comatose
Functional mobility: Roll left and right
Functional mobility: Sit to lying
Functional mobility: lying to sitting on side of bed
Bowel continence
Active diagnosis: Peripheral vascular disease (PVD) or
Peripheral Arterial Disease (PAD)
Active diagnosis: Diabetes mellitus (DM)

Admission

X
X
X
X
X

B0100
GG0160A
GG0160B
GG0160C
H0400

Expired

X
X
X
X
X

X
X

Unplanned Discharge

X
X
X
X
X

Past 2 months: none of the above
Primary Diagnosis in previous setting - ICD Code
Discharge Delay > 24 hours
Reason for Discharge Delay
Discharge return status
Discharge location

Planned Discharge

X

A1810Z
A1820
A1955
A1960
A1970
A2100

Admission

X

Description
Past 2 months: Hospice
Past 2 months: Outpatient services
Past 2 months: Psychiatric hospital or unit
Past 2 months: MR/DD facility

Expired

X
X
X
X
X

Administrative
Items Required
for Data
Submission

Unplanned Discharge

X
X
X
X
X

Items Required
to calculate for
PU (Short-Stay)
Measure

Planned Discharge

X
X
X
X
X

Mandatory Items
for Oct 2012

Admission

X
X

Item No.
A1810I
A1810J
A1810K
A1810L

Expired

Unplanned Discharge

X
X
X
X

Admission

Planned Discharge

Included
on Oct 2012
LTCH Item Set

Rationale for Inclusion as a Mandatory Item for
January 2012

X
X
X
X

X

Required administrative item

risk factor for PU for LTCH patient population
Part of covariate calculation for PU measure
Part of covariate calculation for PU measure
Part of Skin Conditions Section
Part of Skin Conditions Section
Part of numerator calculation for PU measure
Part of Skin Conditions Section

3

X

X

X

X

X

X

Part of Skin Conditions Section

Expired

Unplanned Discharge

Part of Skin Conditions Section

Planned Discharge

X

Admission

X

Expired

Unplanned Discharge

X

Planned Discharge

X

Admission

Unplanned Discharge

X

Expired

Planned Discharge

X

Expired

Admission

Administrative
Items Required
for Data
Submission

Unplanned Discharge

Items Required
to calculate for
PU (Short-Stay)
Measure

Planned Discharge

Item No.

Mandatory Items
for Oct 2012

Admission

Included
on Oct 2012
LTCH Item Set

Rationale for Inclusion as a Mandatory Item for
January 2012

M0300F1

Description
Unstageable - Non-removable dressing: Number of these
unstageable pressure ulcers that were present upon
admission/reentry
Unstageable - Slough and/or eschar: Number of unstageable
pressure ulcers due to coverage of wound bed by slough
and/or eschar

M0300F2

Unstageable - Slough and/or eschar: Number of these
unstageable pressure ulcers that were present upon
admission/reentry

X

X

X

X

X

X

Part of Skin Conditions Section

M0300G1

Unstageable - deep tissue injury: Number of unstageable
pressure ulcers with suspected deep tissue injury in evolution

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of Skin Conditions Section

X

X

X

X

X

X

Part of numerator calculation for PU measure

X

X

X

X

X

X

Part of numerator calculation for PU measure

M0800C

Most severe tissue type for any pressure ulcer
Worsening in Pressure Ulcer Status Since Prior Assessment:
Stage 2
Worsening in Pressure Ulcer Status Since Prior Assessment:
Stage 3
Worsening in Pressure Ulcer Status Since Prior Assessment:
Stage 4

X

X

X

X

X

X

Part of numerator calculation for PU measure

Z0400A

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400B

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400C

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400D

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

M0300E2

M0300G2
M0610A
M0610B
M0610C

M0700
M0800A
M0800B

Unstageable - deep tissue injury: Number of these unstageable
pressure ulcers that were present upon admission/reentry
Dimensions of Unhealed Stage 3 or 4 pressure ulcers or
eschar: Pressure ulcer length
Dimensions of Unhealed Stage 3 or 4 pressure ulcers or
eschar: Pressure ulcer width (same ulcer)
Dimensions of Unhealed Stage 3 or 4 pressure ulcers or
eschar: Pressure ulcer depth (same ulcer)

4

Unplanned Discharge

Expired

Admission

Planned Discharge

Unplanned Discharge

Expired

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400F

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400G

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400H

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400I

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400J

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400K

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0400L

Attestation signature, title, sections, date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0500A

Attestation signature of coordinator verifying completion

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Z0500B

LTCH CARE Data Set Completion Date

X

X

X

X

X

X

X

X

X

X

X

X Required administrative item for data submission

Expired

Planned Discharge

Unplanned Discharge

Admission

Z0400E

Planned Discharge

Description

Admission

Item No.

Expired

Administrative
Items Required
for Data
Submission

Unplanned Discharge

Items Required
to calculate for
PU (Short-Stay)
Measure

Planned Discharge

Mandatory Items
for Oct 2012

Admission

Included
on Oct 2012
LTCH Item Set

Rationale for Inclusion as a Mandatory Item for
January 2012

5