CMS-10409 LTCH CARE Data Set_Expired_v1.01

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 1.01
PATIENT ASSESSMENT FORM - EXPIRED
Administrative Information.

Section A.
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

A0270. Discharge Date. This is the date of death..
_

_
Month

Day

Year

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

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Patient

Identifier

Date

Administrative Information.

Section A.

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.

Expired 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 .

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

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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

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

Year

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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.

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

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