LTCH CARE Item Matrix_V1

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Included on October 1, 2012 Item Sets
Admission
X
X
X
X
X
X
X
X
X

Planned
Discharge
X
X
X
X
X
X
X
X
X

Unplanned
Discharge
X
X
X
X
X
X
X
X
X

Expired
X
X
X
X
X
X
X
X
X

Discharge Date (Date of Death on Expired form)
Patient first name
Patient middle initial
Patient last name

—
X
X
X

X
X
X
X

X
X
X
X

X
X
X
X

Rationale for Inclusion as a Mandatory Item for
October 1, 2012 Data Collection
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
—
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Part of PU denominator calculation, Required
administrative item
Required administrative item
Required administrative item
—
Required administrative item

A0500D
A0600A
A0600B

Patient name suffix
Social Security Number
Patient Medicare/railroad insurance number

X
X
X

X
X
X

X
X
X

X
X
X

—
Required administrative item
—

A0700
A0800
A0900

Patient Medicaid number
Gender
Birth date

X
X
X

X
X
X

X
X
X

X
X
X

A1000A
A1000B
A1000C
A1000D
A1000E
A1000F
A1050

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
—

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

Item No.
A0050
A0055
A0100A
A0100B
A0100C
A0200
A0210
A0220
A0250

Description
Type of Record
Correction Number
Facility National Provider Identifier (NPI)
Facility CMS Certification Number (CCN)
State provider number
Type of provider
Assessment Reference Date
Admission Date
Reason for Assessment

A0270
A0500A
A0500B
A0500C

May 2012

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Included on October 1, 2012 Item Sets
Admission
X
X
X
X
X

Planned
Discharge
—
—
—
—
X

Unplanned
Discharge
—
—
—
—
X

Expired
—
—
—
—
X

X

X

X

X

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
Payer Information: Current Payment Source(s): Title programs
(e.g., III, V, or XX)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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
Payer Information: Current Payment Source(s): Self-pay

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

A1400X

Payer Information: Current Payment Source(s): No Payor
Source
Payer Information: Current Payment Source(s): Unknown

X

X

X

X

A1400Y

Payer Information: Current Payment Source(s): Other

X

X

X

X

A1800
A1810A
A1810B

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 facility or unit
Past 2 months: Home health agency
Past 2 months: Hospice
Past 2 months: Outpatient services
Past 2 months: Psychiatric hospital or unit
Past 2 months: ID/DD facility

X
X
X

—
—
—

—
—
—

—
—
—

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

X
X
X
X
X
X
X
X
X
X

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

Item No.
A1100A
A1100B
A1200
A1300D
A1400A
A1400B
A1400C
A1400D
A1400E
A1400F
A1400G
A1400H
A1400I
A1400J
A1400K

A1810C
A1810D
A1810E
A1810F
A1810G
A1810H
A1810I
A1810J
A1810K
A1810L

May 2012

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)

Rationale for Inclusion as a Mandatory Item for
January 2012
—
—
—
—
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Included on October 1, 2012 Item Sets
Admission
X

Planned
Discharge
—

Unplanned
Discharge
—

Expired
—

Primary Diagnosis in previous setting - ICD Code
Discharge Delay > 24 hours
Reason for Discharge Delay
Discharge return status
Discharge location
Comatose
Functional mobility: Roll left and right
Functional mobility: Sit to lying
Functional mobility: Lying to sitting on side of bed
Bowel incontinence
Active diagnosis: Peripheral vascular disease (PVD) or
Peripheral Arterial Disease (PAD)
Active diagnosis: Diabetes mellitus (DM)
Active diagnosis: Malnutrition (protein or calorie) or at risk for
malnutrition

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
Part of covariate calculation for PU measure

X
X

X
X

X
X

—
—

Part of covariate calculation for PU measure
—

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
Stage 2: Date of oldest Stage 2 pressure ulcer

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

—

—

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

X
X

X
X

X
X

—
—

—
—

X
X

X
X

X
X

—
—

—
—

X

X

X

—

—

X

X

X

—

—

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

X

X

X

—

—

X

X

X

—

—

Item No.
A1810Z

Description
Past 2 months: none of the above

A1820
A1955
A1960
A1970
A2100
B0100
GG0160A
GG0160B
GG0160C
H0400
I0900
I2900
I5600
K0200A
K0200B
M0210
M0300A
M0300B1
M0300B2
M0300B3
M0300C1
M0300C2
M0300D1
M0300D2
M0300E1

M0300E2

M0300F1

M0300F2

May 2012

Rationale for Inclusion as a Mandatory Item for
January 2012
—

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Included on October 1, 2012 Item Sets
Admission
X

Planned
Discharge
X

Unplanned
Discharge
X

Expired
—

Unstageable - deep tissue injury: Number of these unstageable
pressure ulcers that were present upon admission

X

X

X

—

—

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)
Most severe tissue type for any pressure ulcer

X

X

X

—

—

X

X

X

—

—

X

X

X

—

—

X

X

X

—

—

—

X

X

—

Part of numerator calculation for PU measure

—

X

X

—

Part of numerator calculation for PU measure

—

X

X

—

Part of numerator calculation for PU measure

Z0400A

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
Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400B

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400C

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400D

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400E

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400F

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400G

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400H

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400I

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400J

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400K

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0400L

Attestation signature, title, sections, date

X

X

X

X

Required administrative item for data submission

Z0500A

Attestation signature of person verifying completion

X

X

X

X

Required administrative item for data submission

Z0500B

LTCH CARE Data Set Completion Date

X

X

X

X

Required administrative item for data submission

Item No.
M0300G1

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

M0300G2

M0610A
M0610B
M0610C
M0700
M0800A
M0800B
M0800C

May 2012

Rationale for Inclusion as a Mandatory Item for
January 2012
—

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Mandatory Items for October 1, 2012
Admission
X
X
X
X
—
X
X
X
X

Planned
Discharge
X
X
X
X
—
X
X
X
X

Unplanned
Discharge
X
X
X
X
—
X
X
X
X

Expired
X
X
X
X
—
X
X
X
X

—
X
—

X
X
—

X
X
—

X
X
—

A0500C

Discharge Date (Date of Death on Expired form)
Patient first name
Patient middle initial
Patient last name

X

X

X

X

Rationale for Inclusion as a Mandatory Item for
October 1, 2012 Data Collection
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
—
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Part of PU denominator calculation, Required
administrative item
Required administrative item
Required administrative item
—
Required administrative item

A0500D
A0600A
A0600B

Patient name suffix
Social Security Number
Patient Medicare/railroad insurance number

—
X
—

—
X
—

—
X
—

—
X
—

—
Required administrative item
—

A0700
A0800
A0900

Patient Medicaid number
Gender
Birth date

—
X
X

—
X
X

—
X
X

—
X
X

A1000A
A1000B
A1000C
A1000D
A1000E
A1000F
A1050

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

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

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

Item No.
A0050
A0055
A0100A
A0100B
A0100C
A0200
A0210
A0220
A0250

Description
Type of Record
Correction Number
Facility National Provider Identifier (NPI)
Facility CMS Certification Number (CCN)
State provider number
Type of provider
Assessment Reference Date
Admission Date
Reason for Assessment

A0270
A0500A
A0500B

May 2012

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Mandatory Items for October 1, 2012
Admission
—
—
—
—
X

Planned
Discharge
—
—
—
—
X

Unplanned
Discharge
—
—
—
—
X

Expired
—
—
—
—
X

X

X

X

X

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
Payer Information: Current Payment Source(s): Title programs
(e.g., III, V, or XX)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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
Payer Information: Current Payment Source(s): Self-pay

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

A1400X

Payer Information: Current Payment Source(s): No Payor
Source
Payer Information: Current Payment Source(s): Unknown

X

X

X

X

A1400Y

Payer Information: Current Payment Source(s): Other

X

X

X

X

A1800
A1810A
A1810B

—
—
—

—
—
—

—
—
—

—
—
—

A1810C
A1810D
A1810E
A1810F
A1810G
A1810H
A1810I
A1810J
A1810K
A1810L
A1810Z

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 facility or unit
Past 2 months: Home health agency
Past 2 months: Hospice
Past 2 months: Outpatient services
Past 2 months: Psychiatric hospital or unit
Past 2 months: ID/DD facility
Past 2 months: none of the above

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

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

A1820

Primary Diagnosis in previous setting - ICD Code

—

—

—

—

—

Item No.
A1100A
A1100B
A1200
A1300D
A1400A
A1400B
A1400C
A1400D
A1400E
A1400F
A1400G
A1400H
A1400I
A1400J
A1400K

May 2012

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)

Rationale for Inclusion as a Mandatory Item for
January 2012
—
—
—
—
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Mandatory Items for October 1, 2012
Description
Discharge Delay > 24 hours
Reason for Discharge Delay
Discharge return status
Discharge location
Comatose
Functional mobility: Roll left and right
Functional mobility: Sit to lying
Functional mobility: Lying to sitting on side of bed
Bowel incontinence
Active diagnosis: Peripheral vascular disease (PVD) or
Peripheral Arterial Disease (PAD)
Active diagnosis: Diabetes mellitus (DM)
Active diagnosis: Malnutrition (protein or calorie) or at risk for
malnutrition

Admission
—
—
—
—
—
—
—
X
X
X

Planned
Discharge
—
—
—
—
—
—
—
—
—
—

Unplanned
Discharge
—
—
—
—
—
—
—
—
—
—

Expired
—
—
—
—
—
—
—
—
—
—

X
—

—
—

—
—

—
—

Part of covariate calculation for PU measure
—

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
Stage 2: Date of oldest Stage 2 pressure ulcer

X
X
—
—
—
—

—
—
—
—
—
—

—
—
—
—
—
—

—
—
—
—
—
—

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

—

—

—

—

—

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

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—

—

—

—

—

—

—

—

—

—

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

—

—

—

—

—

—

—

—

—

—

M0300G1

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

—

—

—

—

—

M0300G2

Unstageable - deep tissue injury: Number of these unstageable
pressure ulcers that were present upon admission

—

—

—

—

—

Item No.
A1955
A1960
A1970
A2100
B0100
GG0160A
GG0160B
GG0160C
H0400
I0900
I2900
I5600
K0200A
K0200B
M0210
M0300A
M0300B1
M0300B2
M0300B3
M0300C1
M0300C2
M0300D1
M0300D2
M0300E1

M0300E2

M0300F1

M0300F2

May 2012

Rationale for Inclusion as a Mandatory Item for
January 2012
—
—
—
—
—
—
—
Part of covariate calculation for PU measure
Part of covariate calculation for PU measure
Part of covariate calculation for PU measure

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Mandatory Items for October 1, 2012
Item No.
M0610A
M0610B
M0610C
M0700
M0800A
M0800B
M0800C
Z0400A
Z0400B
Z0400C
Z0400D
Z0400E
Z0400F
Z0400G
Z0400H
Z0400I
Z0400J
Z0400K
Z0400L
Z0500A
Z0500B

May 2012

Description
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)
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
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature of person verifying completion
LTCH CARE Data Set Completion Date

Admission
—

Planned
Discharge
—

Unplanned
Discharge
—

Expired
—

Rationale for Inclusion as a Mandatory Item for
January 2012
—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

X

X

—

Part of numerator calculation for PU measure

—

X

X

—

Part of numerator calculation for PU measure

—

X

X

—

Part of numerator 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
X
X

Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Items Required to Calculate Pressure Ulcer Measure
Admission
—
—
—
—
—

Planned
Discharge
—
—
—
—
—

Unplanned
Discharge
—
—
—
—
—

Expired
—
—
—
—
—

Type of provider
Assessment Reference Date
Admission Date
Reason for Assessment

—
—
—
X

—
—
—
X

—
—
—
X

—
—
—
X

A0270
A0500A
A0500B

Discharge Date (Date of Death on Expired form)
Patient first name
Patient middle initial

—
—
—

—
—
—

—
—
—

—
—
—

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

A0500C

Patient last name

—

—

—

—

Required administrative item

A0500D
A0600A
A0600B

Patient name suffix
Social Security Number
Patient Medicare/railroad insurance number

—
—
—

—
—
—

—
—
—

—
—
—

—
Required administrative item
—

A0700
A0800

Patient Medicaid number
Gender

—
—

—
—

—
—

—
—

—
Required administrative item, Gender Disparities

A0900

Birth date

—

—

—

—

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

A1000A
A1000B
A1000C
A1000D
A1000E
A1000F
A1050

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

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

Item No.
A0050
A0055
A0100A
A0100B
A0100C

Description
Type of Record
Correction Number
Facility National Provider Identifier (NPI)
Facility CMS Certification Number (CCN)
State provider number

A0200
A0210
A0220
A0250

May 2012

Rationale for Inclusion as a Mandatory Item for
October 1, 2012 Data Collection
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
—

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Items Required to Calculate Pressure Ulcer Measure
Admission
—
—
—
—
—

Planned
Discharge
—
—
—
—
—

Unplanned
Discharge
—
—
—
—
—

Expired
—
—
—
—
—

—

—

—

—

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
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
Payer Information: Current Payment Source(s): Self-pay

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

A1400X

Payer Information: Current Payment Source(s): No Payor
Source
Payer Information: Current Payment Source(s): Unknown

—

—

—

—

A1400Y

Payer Information: Current Payment Source(s): Other

—

—

—

—

A1800
A1810A
A1810B

Admitted from
Past 2 months: Short-stay acute hospital (IPPS)
Past 2 months: Community residential setting (private home,
assisted living, etc.)

—
—
—

—
—
—

—
—
—

—
—
—

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

A1810C
A1810D
A1810E
A1810F
A1810G
A1810H
A1810I
A1810J
A1810K
A1810L

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 facility or unit
Past 2 months: Home health agency
Past 2 months: Hospice
Past 2 months: Outpatient services
Past 2 months: Psychiatric hospital or unit
Past 2 months: ID/DD facility

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

Item No.
A1100A
A1100B
A1200
A1300D
A1400A
A1400B
A1400C
A1400D
A1400E
A1400F
A1400G
A1400H
A1400I
A1400J
A1400K

May 2012

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)

Rationale for Inclusion as a Mandatory Item for
January 2012
—
—
—
—
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Items Required to Calculate Pressure Ulcer Measure
Admission
—

Planned
Discharge
—

Unplanned
Discharge
—

Expired
—

—
—
—
—
—
—
—
X
X
X

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—

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

X
—

—
—

—
—

—

Part of covariate calculation for PU measure
—

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
Stage 2: Date of oldest Stage 2 pressure ulcer

X
X
—
—
—
—

—
—
—
—
—
—

—
—
—
—
—
—

—
—
—
—
—
—

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

—

—

—

—

—

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

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—

—

—

—

—

—

—

—

—

—

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

—

—

—

—

—

—

—

—

—

—

Item No.
A1810Z

Description
Past 2 months: none of the above

A1820
A1955
A1960
A1970
A2100
B0100
GG0160A
GG0160B
GG0160C
H0400
I0900

Primary Diagnosis in previous setting - ICD Code
Discharge Delay > 24 hours
Reason for Discharge Delay
Discharge return status
Discharge location
Comatose
Functional mobility: Roll left and right
Functional mobility: Sit to lying
Functional mobility: Lying to sitting on side of bed
Bowel incontinence
Active diagnosis: Peripheral vascular disease (PVD) or
Peripheral Arterial Disease (PAD)
Active diagnosis: Diabetes mellitus (DM)
Active diagnosis: Malnutrition (protein or calorie) or at risk for
malnutrition

I2900
I5600
K0200A
K0200B
M0210
M0300A
M0300B1
M0300B2
M0300B3
M0300C1
M0300C2
M0300D1
M0300D2
M0300E1

M0300E2

M0300F1

M0300F2

May 2012

Rationale for Inclusion as a Mandatory Item for
January 2012
—

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Items Required to Calculate Pressure Ulcer Measure
Admission
—

Planned
Discharge
—

Unplanned
Discharge
—

Expired
—

Unstageable - deep tissue injury: Number of these unstageable
pressure ulcers that were present upon admission

—

—

—

—

—

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)
Most severe tissue type for any pressure ulcer

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

X

X

—

Part of numerator calculation for PU measure

—

X

X

—

Part of numerator calculation for PU measure

—

X

X

—

Part of numerator calculation for PU measure

Z0400A
Z0400B

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
Attestation signature, title, sections, date
Attestation signature, title, sections, date

—
—

—
—

—
—

—
—

Required administrative item for data submission
Required administrative item for data submission

Z0400C

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400D

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400E

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400F

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400G

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400H

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400I

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400J

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400K

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0400L

Attestation signature, title, sections, date

—

—

—

—

Required administrative item for data submission

Z0500A

Attestation signature of person verifying completion

—

—

—

—

Required administrative item for data submission

Z0500B

LTCH CARE Data Set Completion Date

—

—

—

—

Required administrative item for data submission

Item No.
M0300G1

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

M0300G2

M0610A
M0610B
M0610C
M0700
M0800A
M0800B
M0800C

May 2012

Rationale for Inclusion as a Mandatory Item for
January 2012
—

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Administrative Items Required for Data Submission
Admission
X
X
X
X
—
X
X
X
X

Planned
Discharge
X
X
X
X
—
X
X
X
X

Unplanned
Discharge
X
X
X
X
—
X
X
X
X

Expired
X
X
X
X
—
X
X
X
X

Discharge Date (Date of Death on Expired form)
Patient first name
Patient middle initial

—
X
—

X
X
—

X
X
—

X
X
—

Rationale for Inclusion as a Mandatory Item for
October 1, 2012 Data Collection
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
—
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Part of PU denominator calculation, Required
administrative item
Required administrative item
Required administrative item
—

A0500C

Patient last name

X

X

X

X

Required administrative item

A0500D
A0600A
A0600B

Patient name suffix
Social Security Number
Patient Medicare/railroad insurance number

—
X
—

—
X
—

—
X
—

—
X
—

—
Required administrative item
—

A0700
A0800
A0900

Patient Medicaid number
Gender
Birth date

—
X
X

—
X
X

—
X
X

—
X
X

A1000A
A1000B
A1000C
A1000D
A1000E
A1000F
A1050

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

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

—
—
—
—
—
—
—

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

Item No.
A0050
A0055
A0100A
A0100B
A0100C
A0200
A0210
A0220
A0250

Description
Type of Record
Correction Number
Facility National Provider Identifier (NPI)
Facility CMS Certification Number (CCN)
State provider number
Type of provider
Assessment Reference Date
Admission Date
Reason for Assessment

A0270
A0500A
A0500B

May 2012

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Administrative Items Required for Data Submission
Admission
—
—
—
—
X

Planned
Discharge
—
—
—
—
X

Unplanned
Discharge
—
—
—
—
X

Expired
—
—
—
—
X

X

X

X

X

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
Payer Information: Current Payment Source(s): Title programs
(e.g., III, V, or XX)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

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
Payer Information: Current Payment Source(s): Self-pay

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

A1400X

Payer Information: Current Payment Source(s): No Payor
Source
Payer Information: Current Payment Source(s): Unknown

X

X

X

X

A1400Y

Payer Information: Current Payment Source(s): Other

X

X

X

X

A1800
A1810A
A1810B

Admitted from
Past 2 months: Short-stay acute hospital (IPPS)
Past 2 months: Community residential setting (private home,
assisted living, etc.)

—
—
—

—
—
—

—
—
—

—
—
—

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

A1810C
A1810D
A1810E
A1810F
A1810G
A1810H
A1810I
A1810J
A1810K
A1810L
A1810Z

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 facility or unit
Past 2 months: Home health agency
Past 2 months: Hospice
Past 2 months: Outpatient services
Past 2 months: Psychiatric hospital or unit
Past 2 months: ID/DD facility
Past 2 months: none of the above

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

—
—
—
—
—
—
—
—
—
—
—

Item No.
A1100A
A1100B
A1200
A1300D
A1400A
A1400B
A1400C
A1400D
A1400E
A1400F
A1400G
A1400H
A1400I
A1400J
A1400K

May 2012

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)

Rationale for Inclusion as a Mandatory Item for
January 2012
—
—
—
—
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes
Required administrative item, Type of Insurance
affects Quality Outcomes

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Administrative Items Required for Data Submission
Item No.
A1820
A1955
A1960
A1970
A2100
B0100
GG0160A
GG0160B
GG0160C
H0400
I0900
I2900
I5600
K0200A
K0200B
M0210
M0300A
M0300B1
M0300B2
M0300B3
M0300C1
M0300C2
M0300D1
M0300D2
M0300E1

M0300E2

M0300F1

M0300F2

M0300G1

May 2012

Description
Primary Diagnosis in previous setting - ICD Code
Discharge Delay > 24 hours
Reason for Discharge Delay
Discharge return status
Discharge location
Comatose
Functional mobility: Roll left and right
Functional mobility: Sit to lying
Functional mobility: Lying to sitting on side of bed
Bowel incontinence
Active diagnosis: Peripheral vascular disease (PVD) or
Peripheral Arterial Disease (PAD)
Active diagnosis: Diabetes mellitus (DM)
Active diagnosis: Malnutrition (protein or calorie) or at risk for
malnutrition

Admission
—
—
—
—
—
—
—
—
—
—
—

Planned
Discharge
—
—
—
—
—
—
—
—
—
—
—

Unplanned
Discharge
—
—
—
—
—
—
—
—
—
—
—

Expired
—
—
—
—
—
—
—
—
—
—
—

Rationale for Inclusion as a Mandatory Item for
January 2012
—
—
—
—
—
—
—
—
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
—

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
Stage 2: Date of oldest Stage 2 pressure ulcer

—
—
—
—
—
—

—
—
—
—
—
—

—
—
—
—
—
—

—
—
—
—
—
—

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

—

—

—

—

—

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

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—
—

—

—

—

—

—

—

—

—

—

—

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

—

—

—

—

—

—

—

—

—

—

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

—

—

—

—

—

LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD EVALUATION DATA SET, ITEM MATRIX, Version 1.01:
Administrative Items Required for Data Submission
Admission
—

Planned
Discharge
—

Unplanned
Discharge
—

Expired
—

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)
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
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature, title, sections, date
Attestation signature of person verifying completion
LTCH CARE Data Set Completion Date

—

—

—

—

Part of numerator calculation for PU measure

—

—

—

—

Part of numerator calculation for PU measure

—

—

—

—

Part of numerator 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
X
X

Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission
Required administrative item for data submission

Item No.
M0300G2

Description
Unstageable - deep tissue injury: Number of these unstageable
pressure ulcers that were present upon admission

M0610A
M0610B
M0610C
M0700
M0800A
M0800B
M0800C
Z0400A
Z0400B
Z0400C
Z0400D
Z0400E
Z0400F
Z0400G
Z0400H
Z0400I
Z0400J
Z0400K
Z0400L
Z0500A
Z0500B

May 2012

Rationale for Inclusion as a Mandatory Item for
January 2012
—