CMS-10409 LTCH Care Data Set Planned Discharge

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 2.00
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

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.
_

_
Month

Day

Year

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v2.00 DRAFT
Effective January 1, 2014

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Patient

Identifier

Section A.

Date

Administrative Information.

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):

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v2.00 DRAFT
Effective January 1, 2014

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Patient

Identifier

Section A.

Date

Administrative Information.

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.

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 .

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v2.00 DRAFT
Effective January 1, 2014

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Patient

Identifier

Section A.

Date

Administrative Information.

A2110. 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

A2500. Program Interruption(s) .
Enter Code

Program Interruptions
Skip to M0210, Unhealed Pressure Ulcer(s)
0. No
1. Yes
Continue to A2510, Number of Program Interruptions During This Stay in This Facility.

A2510. Number of Program Interruptions During This Stay in This Facility
Enter Number

Number of Program Interruptions During This Stay in This Facility. Code only if A2500 is equal to 1.

A2520. Program Interruption Dates. Code only if A2510 is greater than or equal to 01.
A1. Most Recent Interruption Start Date

_

_
Month

Year

Day

A2. Most Recent Interruption End Date

_

_
Month

Year

Day

B1. Second Most Recent Interruption Start Date. Code only if A2510 is greater than 01.

_

_
Month

Year

Day

B2. Second Most Recent Interruption End Date. Code only if A2510 is greater than 01.

_

_
Month

Year

Day

C1. Third Most Recent Interruption Start Date. Code only if A2510 is greater than 02.

_

_
Month

Year

Day

C2. Third Most Recent Interruption End Date. Code only if A2510 is greater than 02.

_

_
Month

Day

Year

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v2.00 DRAFT
Effective January 1, 2014

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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 O0250, Influenza Vaccine
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

Enter Number

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

Skip to M0300D, Stage 4.

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 M0300C, Stage 3.

Skip to M0300E, Unstageable: Nonremovable 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 - Nonremovable dressing: Known but not stageable due to nonremovable dressing/device.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers due to nonremovable 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, v2.00 DRAFT
Effective January 1, 2014

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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

Enter Number

1. Number of unstageable pressure ulcers with suspected deep tissue injury in evolution - If 0
in Pressure Ulcer Status Since Prior Assessment

Skip to M0800, Worsening

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

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, v2.00 DRAFT
Effective January 1, 2014

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Patient

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0250. Influenza Vaccine - Refer to current version of LTCHQR Program Manual for current influenza season and reporting period..
Enter Code

A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No... Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes
Continue to O250B, Date influenza vaccine received.
B. Date influenza vaccine received

_

_
Month
Enter Code

Complete date and skip to Z0400, Signature of Persons Completing the Assessment

Day

Year

C. If influenza vaccine not received, state reason:
1. Patient not in this facility during this year's influenza vaccination season
2. Received outside of this facility
3. Not eligible - medical contraindication
4. Offered and declined
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage
9. None of the above

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v2.00 DRAFT
Effective January 1, 2014

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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

Year

Planned Discharge Long Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v2.00 DRAFT
Effective January 1, 2014

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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
0938-1163. 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, v2.00 DRAFT
Effective January 1, 2014

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