| Item No. |
Description |
Admission |
Planned Discharge |
Unplanned Discharge |
Expired |
Rationale for Inclusion as a Required Item for January 1, 2014 Data Collection |
| A0050 |
Type of Record |
R |
R |
R |
R |
System cannot accept record without response |
| A0100A |
Facility National Provider Identifier (NPI) |
V |
V |
V |
V |
— |
| A0100B |
Facility CMS Certification Number (CCN) |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| A0100C |
State provider number |
V |
V |
V |
V |
— |
| A0200 |
Type of provider |
R |
R |
R |
R |
System cannot accept record without response |
| A0210 |
Assessment Reference Date |
R |
R |
R |
R |
System cannot accept record without response |
| A0220 |
Admission Date |
R |
R |
R |
R |
System cannot accept record without response |
| A0250 |
Reason for Assessment |
R |
R |
R |
R |
System cannot accept record without response |
| A0270 |
Discharge Date (Date of Death on Expired form) |
N/A |
R |
R |
R |
System cannot accept record without response |
| A0500A |
Patient first name |
R1 |
R1 |
R1 |
R1 |
Required, however, system accepts default response of hyphen or dash |
| A0500B |
Patient middle initial |
V |
V |
V |
V |
— |
| A0500C |
Patient last name |
R |
R |
R |
R |
System cannot accept record without response |
| A0500D |
Patient name suffix |
V |
V |
V |
V |
— |
| A0600A |
Social Security Number |
R1 |
R1 |
R1 |
R1 |
Required, however, system accepts default response of hyphen or dash |
| A0600B |
Patient Medicare/railroad insurance number |
V |
V |
V |
V |
— |
| A0700 |
Patient Medicaid number |
V |
V |
V |
V |
— |
| A0800 |
Gender |
R |
R |
R |
R |
System cannot accept record without response |
| A0900 |
Birth date |
R(BYR) |
R(BYR) |
R(BYR) |
R(BYR) |
Birth year required |
| A1000A |
Race/Ethnicity: American Indian or Alaska Native |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1000B |
Race/Ethnicity: Asian |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1000C |
Race/Ethnicity: Black or African American |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1000D |
Race/Ethnicity: Hispanic or Latino |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1000E |
Race/Ethnicity: Native Hawaiian/Pacific Islander |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1000F |
Race/Ethnicity: White |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1100A |
Does the Patient need or want an interpreter |
V-DR |
N/A |
N/A |
N/A |
— |
| A1100B |
Preferred language |
V |
N/A |
N/A |
N/A |
— |
| A1200 |
Marital status |
V-DR |
N/A |
N/A |
N/A |
— |
| A1400A |
Payer Information: Current Payment Source(s): Medicare (traditional FFS) |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400B |
Payer Information: Current Payment Source(s): Medicare (managed care, Part C, Medicare Advantage) |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400C |
Payer Information: Current Payment Source(s): Medicaid (traditional FFS) |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400D |
Payer Information: Current Payment Source(s): Medicaid (managed care) |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400E |
Payer Information: Current Payment Source(s): Workers' compensation |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400F |
Payer Information: Current Payment Source(s): Title programs (e.g., III, V, or XX) |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400G |
Payer Information: Current Payment Source(s): Other government (TRICARE, VA) |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400H |
Payer Information: Current Payment Source(s):Private insurance/Medigap |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400I |
Payer Information: Current Payment Source(s): Private managed care |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400J |
Payer Information: Current Payment Source(s): Self-pay |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400K |
Payer Information: Current Payment Source(s): No Payor Source |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400X |
Payer Information: Current Payment Source(s): Unknown |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1400Y |
Payer Information: Current Payment Source(s): Other |
V-DR |
V-DR |
V-DR |
V-DR |
— |
| A1802 |
Admitted from |
V-DR |
N/A |
N/A |
N/A |
— |
| A2110 |
Discharge location |
N/A |
V-DR |
V-DR |
N/A |
— |
| A2500 |
Program Interruption(s) |
N/A |
V |
V |
N/A |
|
| A2510 |
Number of program interruptions during this stay in this facility |
N/A |
V |
V |
N/A |
— |
| A2520A1 |
Most Recent Interruption Start Date |
N/A |
V |
V |
N/A |
— |
| A2520A2 |
Most Recent Interruption End Date |
N/A |
V |
V |
N/A |
— |
| A2520B1 |
Second Most Recent Interruption Start Date |
N/A |
V |
V |
N/A |
— |
| A2520B2 |
Second Most Recent Interruption End Date |
N/A |
V |
V |
N/A |
— |
| A2520C1 |
Third Most Recent Interruption Start Date |
N/A |
V |
V |
N/A |
— |
| A2520C2 |
Third Most Recent Interruption End Date |
N/A |
V |
V |
N/A |
— |
| B0100 |
Comatose |
V-DR |
N/A |
N/A |
N/A |
— |
| GG0160A |
Functional mobility: Roll left and right |
V-DR |
N/A |
N/A |
N/A |
— |
| GG0160B |
Functional mobility: Sit to lying |
V-DR |
N/A |
N/A |
N/A |
— |
| GG0160C |
Functional mobility: Lying to sitting on side of bed |
M-R |
N/A |
N/A |
N/A |
Part of covariate calculation for PU measure |
| H0400 |
Bowel Continence |
M-R |
N/A |
N/A |
N/A |
Part of covariate calculation for PU measure |
| I0900 |
Active diagnosis: Peripheral vascular disease (PVD) or Peripheral Arterial Disease (PAD) |
M-R |
N/A |
N/A |
N/A |
Part of covariate calculation for PU measure |
| I2900 |
Active diagnosis: Diabetes mellitus (DM) |
M-R |
N/A |
N/A |
N/A |
Part of covariate calculation for PU measure |
| I5600 |
Active diagnosis: Malnutrition (protein or calorie) or at risk for malnutrition |
V-DR |
N/A |
N/A |
N/A |
— |
| K0200A |
Height (in inches) |
M-R |
N/A |
N/A |
N/A |
Part of covariate calculation for PU measure |
| K0200B |
Weight (in pounds) |
M-R |
N/A |
N/A |
N/A |
Part of covariate calculation for PU measure |
| M0210 |
Unhealed pressure ulcer(s) |
R |
R |
R |
N/A |
System cannot accept record without response |
| M0300A |
Stage 1: Number of stage 1 pressure ulcers |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300B1 |
Stage 2: Number of stage 2 pressure ulcers |
M-R |
M-R |
M-R |
N/A |
Used for PU Measure consistency checks |
| M0300B2 |
Stage 2: Number of these stage 2 pressure ulcers that were present upon admission |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300C1 |
Stage 3: Number of stage 3 pressure ulcers |
M-R |
M-R |
M-R |
N/A |
Used for PU Measure consistency checks |
| M0300C2 |
Stage 3: Number of these stage 3 pressure ulcers that were present upon admission |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300D1 |
Stage 4: Number of stage 4 pressure ulcers |
M-R |
M-R |
M-R |
N/A |
Used for PU Measure consistency checks |
| M0300D2 |
Stage 4: Number of these stage 4 pressure ulcers that were present upon admission |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300E1 |
Unstageable - Nonremovable dressing: Number of unstageable pressure ulcers due to nonremovable dressing/device |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300E2 |
Unstageable - Nonremovable dressing: Number of these unstageable pressure ulcers that were present upon admission |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300F1 |
Unstageable - Slough and/or eschar: Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300F2 |
Unstageable - Slough and/or eschar: Number of these unstageable pressure ulcers that were present upon admission |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300G1 |
Unstageable - deep tissue injury: Number of unstageable pressure ulcers with suspected deep tissue injury in evolution |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0300G2 |
Unstageable - deep tissue injury: Number of these unstageable pressure ulcers that were present upon admission |
RC-V |
RC-V |
RC-V |
N/A |
— |
| M0800A |
Worsening in Pressure Ulcer Status Since Prior Assessment: Stage 2 |
N/A |
M-R |
M-R |
N/A |
Part of numerator calculation for PU measure |
| M0800B |
Worsening in Pressure Ulcer Status Since Prior Assessment: Stage 3 |
N/A |
M-R |
M-R |
N/A |
Part of numerator calculation for PU measure |
| M0800C |
Worsening in Pressure Ulcer Status Since Prior Assessment: Stage 4 |
N/A |
M-R |
M-R |
N/A |
Part of numerator calculation for PU measure |
| O0250A |
Influenza vaccine - did patient receive influenza vaccine in this facility for this year's influenza vaccination season |
M-R |
M-R |
M-R |
N/A |
Part of numerator calculation for Influenza vaccination measure |
| O0250B |
Influenza vaccine - Date influenza vaccine received |
M-R |
M-R |
M-R |
N/A |
Part of numerator calculation for Influenza vaccination measure |
| O0250C |
Influenza vaccine - if influenza vaccine not received, state reason |
M-R |
M-R |
M-R |
N/A |
Part of numerator calculation for Influenza vaccination measure |
| Z0400A |
Attestation signature, title, sections, date |
R |
R |
R |
R |
— |
| Z0400B |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400C |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400D |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400E |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400F |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400G |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400H |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400I |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400J |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400K |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0400L |
Attestation signature, title, sections, date |
RC-V |
RC-V |
RC-V |
RC-V |
— |
| Z0500A |
Attestation signature of person verifying completion |
R |
R |
R |
R |
— |
| Z0500B |
LTCH CARE Data Set Completion Date |
R |
R |
R |
R |
System cannot accept record without response |
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Key: |
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N/A: Not Applicable |
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R: Required |
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M-R: Required for Measure Calculation |
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BYR: Birth Year Required |
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R1: Required, however, system accepts default response of hyphen or dash |
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V: Voluntary |
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RC-V: Recommended but Voluntary |
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V-DR: Voluntary, default response required |
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