Form CMS-10409 LTCH CARE Data Set_Planned Discharge_v1.01

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 1.01
PATIENT ASSESSMENT FORM - PLANNED DISCHARGE

Section A.

Administrative Information.

A0050. Type of Record.
Enter Code

1. Add new assessment/record
2. Modify existing record
3. Inactivate existing record

A0055. Correction Number.
Enter Number

Enter the number of correction requests to modify/inactivate the existing record, including the present one.
Enter 00 for new record

A0100. Facility Provider Numbers. Enter Code in boxes provided..
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Provider Number:

A0200. Type of Provider.
Enter Code

3. Long-term Care Hospital

A0210. Assessment Reference Date.
Observation end date:

_

_
Month

Year

Day

A0220. Admission Date
_

_
Month

Day

Year

A0250. Reason for Assessment .
Enter Code

01.
10.
11.
12.

Admission
Planned discharge
Unplanned discharge .
Expired

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section A.

Date

Administrative Information.

A0270. Discharge Date.
_

_
Month

Year

Day

Patient Demographic Information .
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 (or comparable railroad insurance 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

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section A.

Date

Administrative Information.

A1400. Payer Information.
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care).
E. Workers' compensation
F. Title programs (e.g., Title III, V, or XX).
G. Other government (e.g., TRICARE, VA, etc.)
H. Private insurance/Medigap.
I. Private managed care
J. Self-pay.
K. No payor source
X. Unknown
Y. Other .

A1955. Discharge Delay
Enter Code

Was the patient's discharge delayed for at least 24 hours?
0. No
Skip to A1970, Discharge Return Status
1. Yes

A1960. Reason for Discharge Delay
Enter Code

01.
02.
03.
04.
98.

No bed available at receiving hospital/facility
Services, equipment or medications not available (e.g., home health care, durable medical equipment, IV medications)
Family/support (e.g., family could not pick patient up)
Medical (patient condition changed)
Other

A1970. Discharge Return Status
Enter Code

1. Anticipated
2. Not Anticipated

A2100. Discharge Location
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
12.
98.

Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)
Long-term care facility
Skilled nursing facility (SNF)
Hospital emergency department
Short-stay acute hospital (IPPS)
Long-term care hospital (LTCH)
Inpatient rehabilitation facility or unit (IRF)
Psychiatric hospital or unit
ID/DD facility
Hospice
Discharged Against Medical Advice
Other

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section B.

Date

Hearing, Speech, and Vision.

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness at time of assessment..
0. No
1. Yes

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Section GG.

Identifier

Date

Functional Status: Usual Performance.

GG0160. Functional Mobility
(Complete during the 3-day assessment period.)
Code the patient's usual performance using the 6-point scale below.
CODING:
Safety and Quality of Performance - If helper assistance is required
because patient's performance is unsafe or of poor quality, score
according to amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself
with no assistance from a helper.
05. Setup or clean-up assistance - Helper SETS UP or CLEANS UP;
patient completes activity. Helper assists only prior to or
following the activity.
04. Supervision or touching assistance - Helper provides VERBAL
CUES or TOUCHING/ STEADYING assistance as patient completes
activity. Assistance may be provided throughout the activity or
intermittently.
.
03. Partial/moderate assistance - Helper does LESS THAN HALF
the effort. Helper lifts, holds or supports trunk or limbs, but
provides less than half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN
HALF the effort. Helper lifts or holds trunk or limbs and provides
more than half the effort.
01. Dependent - Helper does ALL of the effort. Patient does none
of the effort to complete the task.

Enter Codes in Boxes.
A. Roll left and right: The ability to roll from lying on
back to left and right side, and roll back to back.
B. Sit to lying: The ability to move from sitting on side
of bed to lying flat on the bed.
C. Lying to Sitting on Side of Bed: The ability to safely
move from lying on the back to sitting on the side of
the bed with feet flat on the floor, no back support.

07. Patient refused
09. Not applicable
If activity was not attempted, code:
88. Not attempted due to medical condition or safety concerns

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section H.

Date

Bladder and Bowel.

H0400. Bowel Continence
(Complete during the 3-day assessment period.) .
Enter Code

Bowel continence - Select the one category that best describes the patient..
0. Always continent
1. Occasionally incontinent (one episode of bowel incontinence)
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)
3. Always incontinent (no episodes of continent bowel movements)
9. Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days.

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section I.

Date

Active Diagnoses.

For this section, indicate the presence of the following conditions, based on a review of the patient's clinical records at the time
of assessment..
Check all that apply.
Heart/Circulation.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Metabolic.
I2900. Diabetes Mellitus (DM)
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Section K.

Identifier

Date

Swallowing/Nutritional Status.

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since admission.
inches

pounds

B. Weight (in pounds). Base weight on most recent measure in last 3 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section M.

Date

Skin Conditions.

Report based on highest stage of existing ulcer(s) at its worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcer(s).
Enter Code

Does this patient have one or more unhealed pressure ulcer(s) at Stage 1 or higher?
0. No
Skip to Z0400, Signature of Persons Completing the Assessment
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers at Each Stage.
Enter Number

Enter Number

A. Number of Stage 1 pressure ulcers.
Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0

Enter Number

Skip to M0300C, Stage 3.

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
3. Date of oldest Stage 2 pressure ulcer - Enter dashes if date is unknown:

_

_
Month

Enter Number

Day

Year

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers - If 0

Enter Number

Enter Number

2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers - If 0

Enter Number

Skip to M0300D, Stage 4.

Skip to M0300E, Unstageable: Non-removable dressing.

2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
E. Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers due to non-removable dressing/device - If 0
Slough and/or eschar.

Skip to M0300F, Unstageable:

2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0
Unstageable: Deep tissue injury.

Skip to M0300G,

2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.

M0300 continued on next page.

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012

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Patient

Identifier

Section M.

Date

Skin Conditions.

M0300. Current Number of Unhealed Pressure Ulcers at Each Stage - Continued.
G. Unstageable - Deep tissue injury: Suspected deep tissue injury in evolution.
Enter Number

1. Number of unstageable pressure ulcers with suspected deep tissue injury in evolution - If 0
of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar.

Enter Number

Skip to M0610, Dimension

2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.

M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar.
Complete only if M0300C1, M0300D1 or M0300F1 is greater than 0.
If the patient has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure
ulcer with the largest surface area (length x width) and record in centimeters:

.

cm

.

cm

.

cm

A. Pressure ulcer length: Longest length in any direction.

B. Pressure ulcer width: Widest width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length.
C. Pressure ulcer depth: Depth of the same pressure ulcer from the visible surface to the deepest area (if depth is unknown,
enter a dash in each box).

M0700. Most Severe Tissue Type for Any Pressure Ulcer.
Enter Code

Select the best description of the most severe type of tissue present in any pressure ulcer bed, consider all pressure ulcers.
1. Epithelial tissue - new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin.
2. Granulation tissue - pink or red tissue with shiny, moist, granular appearance.
3. Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous.
4. Necrotic tissue (Eschar) - black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder
than surrounding skin.

M0800. Worsening in Pressure Ulcer Status Since Prior Assessment .
Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment.
If no current pressure ulcer at a given stage, enter 0.
Enter Number

Enter Number

Enter Number

A. Stage 2.

B. Stage 3.

C. Stage 4.

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012 Page 10 of 12

Patient

Section Z.

Identifier

Date

Assessment Administration.

Z0400. Signature of Persons Completing the Assessment
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 this information is used as a basis for payment from federal funds. I further
understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on
the accuracy and truthfulness of this information, and that submitting false information may subject my organization to a 2% reduction in the
Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf.
Signature.

Title.

Date Section
Completed.

Sections.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Assessment Completion.
A. Signature:

B. LTCH CARE Data Set Completion Date:

_

_
Month

Day

Year

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012 Page 11 of 12

Patient

Identifier

Date

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. The valid OMB control number for this information collection is
0938-1037. The time required to complete this information collection is estimated to average 5 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. 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.

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v1.01 May 2012 Page 12 of 12