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pdfAPPENDIX A
LONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD & EVALUATION DATA SET, ITEM MATRIX, V3.00 - FINAL
A0050
Type of Record
R
Planned
Discharge
R
R
Rationale for Inclusion as a Required Item
for April 1, 2016 Data Collection
System cannot accept record without response
A0100A
National Provider Identifier (NPI)
R
R
R
R
—
N
A0100B
CMS Certification Number (CCN)
R
R
R
R
—
N
A0100C
State Medicaid Provider Number
RIAV
RIAV
RIAV
RIAV
—
N
A0200
Type of Provider
R
R
R
R
System cannot accept record without response
N
A0210
Assessment Reference Date
R
R
R
R
System cannot accept record without response
N
A0220
Admission Date
R
R
R
R
System cannot accept record without response
N
A0250
Reason for Assessment
R
R
R
R
System cannot accept record without response
N
A0270
Discharge Date (Date of Death on Expired
form)
N/A
R
R
R
System cannot accept record without response
N
A0500A
First name
R
R
R
R
Required, however, system accepts default
response of hyphen or dash
N
A0500B
Middle initial
RIAV
RIAV
RIAV
RIAV
—
N
A0500C
Last name
R
R
R
R
System cannot accept record without response
N
A0500D
Suffix
RIAV
RIAV
RIAV
RIAV
—
N
A0600A
Social Security Number
R
R
R
R
Required, however, system accepts default
response of hyphen or dash
N
A0600B
Medicare number
RIAV
RIAV
RIAV
RIAV
—
N
A0700
Medicaid Number
RIAV
RIAV
RIAV
RIAV
—
N
A0800
Gender
R
R
R
R
System cannot accept record without response
N
A0900
Birth Date
R
R
R
R
Birth year required
N
A1000A
Race/Ethnicity: American Indian or Alaska
Native
RIAV
RIAV
RIAV
RIAV
—
N
Item No.
Description
For Key, see page 17 of this file
Admission
Unplanned
Discharge
R
Expired
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
N
Page 1
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Race/Ethnicity: Asian
RIAV
RIAV
RIAV
RIAV
—
N
A1000C
Race/Ethnicity: Black or African American
RIAV
RIAV
RIAV
RIAV
—
N
A1000D
Race/Ethnicity: Hispanic or Latino
RIAV
RIAV
RIAV
RIAV
—
N
A1000E
Race/Ethnicity: Native Hawaiian or Other
Pacific Islander
RIAV
RIAV
RIAV
RIAV
—
N
A1000F
Race/Ethnicity: White
RIAV
RIAV
RIAV
RIAV
—
N
A1100A
Does the Patient need or want an interpreter to
communicate with a doctor or health care
staff?
RIAV
N/A
N/A
N/A
—
N
A1100B
Preferred language
RIAV
N/A
N/A
N/A
—
N
A1200
Marital Status
RIAV
N/A
N/A
N/A
—
N
A1400A
Payer Information: Medicare (traditional feefor-service)
RIAV
RIAV
RIAV
RIAV
—
N
A1400B
Payer Information: Medicare (managed care,
/Part C, /Medicare Advantage)
RIAV
RIAV
RIAV
RIAV
—
N
A1400C
Payer Information: Medicaid (traditional feefor-service)
RIAV
RIAV
RIAV
RIAV
—
N
A1400D
Payer Information: Medicaid (managed care)
RIAV
RIAV
RIAV
RIAV
—
N
A1400E
Payer Information: Workers' compensation
RIAV
RIAV
RIAV
RIAV
—
N
A1400F
Payer Information: Title programs (e.g., Title
III, V, or XX)
RIAV
RIAV
RIAV
RIAV
—
N
A1400G
Payer Information: Other government (e.g.,
TRICARE, VA, etc.)
RIAV
RIAV
RIAV
RIAV
—
N
A1400H
Payer Information: Private insurance/Medigap
RIAV
RIAV
RIAV
RIAV
—
N
A1400I
Payer Information: Private managed care
RIAV
RIAV
RIAV
RIAV
—
N
A1400J
Payer Information: Self-pay
RIAV
RIAV
RIAV
RIAV
—
N
Item No.
Description
A1000B
For Key, see page 17 of this file
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 2
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Payer Information: No payor source
RIAV
RIAV
RIAV
RIAV
—
N
A1400X
Payer Information: Unknown
RIAV
RIAV
RIAV
RIAV
—
N
A1400Y
Payer Information: Other
RIAV
RIAV
RIAV
RIAV
—
N
A1802
Admitted From
R
N/A
N/A
N/A
—
N
A2110
Discharge Location
N/A
R
R
N/A
—
N
A2500
Program Interruption(s)
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2510
Number of Program Interruptions During This
Stay in This Facility
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525A1
First Interruption Start Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525A2
First Interruption End Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525B1
Second Interruption Start Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525B2
Second Interruption End Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525C1
Third Interruption Start Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525C2
Third Interruption End Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525D1
Fourth Interruption Start Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525D2
Fourth Interruption End Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
A2525E1
Fifth Interruption Start Date
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
Item No.
Description
A1400K
For Key, see page 17 of this file
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 3
Item No.
Description
A2525E2
Fifth Interruption End Date
B0100
Comatose
BB0700
Expression of Ideas and Wants
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
N/A
R
R
N/A
Complete the program interruption items if it
applies to the patient.
N
R
R
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
N
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
Y
Y
R
Understanding Verbal Content
C1610A
Signs and Symptoms of Delirium (from
CAM©): Acute Onset and Fluctuating Course
- Is there evidence of an acute change in
mental status from the patient's baseline?
R
R
R
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
C1610B
Signs and Symptoms of Delirium (from
CAM©): Acute Onset and Fluctuating Course
- Did the (abnormal) behavior fluctuate during
the day, that is, tent to come and go or
increase and decrease in severity?
R
R
R
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.Covariate for Function Mobility QM.
Y
C1610C
Signs and Symptoms of Delirium (from
CAM©): Inattention - Did the patient have
difficulty focusing attention, for example,
being easily distracted or having difficulty
keeping track of what was said?
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
Y
C1610D
Signs and Symptoms of Delirium (from
CAM©): Disorganized Thinking - Was the
patient's thinking disorganized or incoherent,
such as rambling or irrelevant conversation,
unclear or illogical flow of ideas, or
unpredictable switching from subject to
subject?
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
Y
R
R
R
N/A
BB0800
For Key, see page 17 of this file
R
R
R
R
N/A
R
R
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 4
Admission
Planned
Discharge
Item No.
Description
C1610E1
Signs and Symptoms of Delirium (from
CAM©): Altered Level of Consciousness Overall, how would you rate the patient's
level of consistency? Alert (Normal)
C1610E2
Signs and Symptoms of Delirium (from
CAM©): Altered Level of Consciousness Overall, how would you rate the patient's
level of consistency? Vigilant (hyperalert) or
Lethargic (drowsy, easily aroused) or Stupor
(difficult to arouse) or Coma (unarousable)
R
R
GG0100B
Prior Functioning: Everyday Activities.
Indoor Mobility (Ambulation)
R
GG0110
Prior Device Use
GG0130A1
Self-Care: Eating: Admission Performance
Unplanned
Discharge
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
Y
R
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
Y
N/A
N/A
N/A
Part of covariate calculation for LTCH
Mobility QM.
Y
R
N/A
N/A
N/A
Covariate for LTCH Function Mobility QM.
Y
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
Y
R
R
R
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
Self-Care: Oral hygiene: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0130B2
Self-Care: Oral hygiene: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0130B3
Self-Care: Oral hygiene: Discharge
Performance
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0130A2
Self-Care: Eating: Discharge Goal
GG0130A3
Self-Care: Eating: Discharge Performance
GG0130B1
For Key, see page 17 of this file
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 5
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Self-Care: Toileting hygiene: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0130C2
Self-Care: Toileting hygiene: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0130C3
Self-Care: Toileting hygiene: Discharge
Performance
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0130D1
Self-Care: Wash upper body: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0130D2
Self-Care: Wash upper body: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0130D3
Self-Care: Wash upper body: Discharge
Performance
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
N
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
N
Item No.
Description
GG0130C1
GG0170A1
GG0170A2
GG0170A3
Mobility: Roll left and right: Admission
Performance
Mobility: Roll left and right: Discharge Goal
Mobility: Roll left and right: Discharge
Performance
For Key, see page 17 of this file
R
R
N/A
N/A
N/A
R
N/A
N/A
N/A
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 6
Item No.
Description
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
N
GG0170B1
Mobility: Sit to lying: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
GG0170B2
Mobility: Sit to lying: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
N
N
GG0170B3
Mobility: Sit to lying: Discharge Performance
N/A
R
N/A
GG0170C1
Mobility: Lying to sitting on side of bed:
Admission Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Mobility QM.
GG0170C2
Mobility: Lying to sitting on side of bed:
Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
N
Y
Y
GG0170C3
Mobility: Lying to sitting on side of bed:
Discharge Performance
GG0170D1
Mobility: Sit to stand: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.Used to calculate change in mobility
value for the LTCH Function Mobility QM.
GG0170D2
Mobility: Sit to stand: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
For Key, see page 17 of this file
N/A
R
N/A
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 7
Item No.
GG0170D3
Description
Admission
Mobility: Sit to stand: Discharge Performance
GG0170E1
Mobility: Chair/bed-to-chair transfer:
Admission Performance
GG0170E2
Mobility: Chair/bed-to-chair transfer:
Discharge Goal
GG0170E3
Mobility: Chair/bed-to-chair transfer:
Discharge Performance
N/A
R
R
N/A
Planned
Discharge
R
N/A
N/A
R
Unplanned
Discharge
N/A
N/A
N/A
N/A
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
Y
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
Y
Y
GG0170F1
Mobility: Toilet transfer: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
GG0170F2
Mobility: Toilet transfer: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0170F3
Mobility: Toilet transfer: Discharge
Performance
Y
GG0170H1
Mobility: Does the patient walk?
Y
For Key, see page 17 of this file
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.Used to calculate change in mobility
value for the LTCH Function Mobility QM.
R
N/A
N/A
N/A
Item added to reduce burden. If GG0170H=0,
skip to GG0170Q, Wheelchair or Scooter.
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 8
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
N/A
R
N/A
N/A
Item added to reduce burden. If GG0170H=0,
skip to GG0170Q, Wheelchair or Scooter.
Y
Mobility: Walk 10 feet: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170I2
Mobility: Walk 10 feet: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0170I3
Mobility: Walk 10 feet: Discharge
Performance
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
Y
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
Y
Y
Y
Item No.
Description
GG0170H3
Mobility: Does the patient walk?
GG0170I1
N/A
GG0170J1
Mobility: Walk 50 feet with two turns:
Admission Performance
GG0170J2
Mobility: Walk 50 feet with two turns:
Discharge Goal
R
R
R
N/A
N/A
N/A
N/A
N/A
GG0170J3
Mobility: Walk 50 feet with two turns:
Discharge Performance
GG0170K1
Mobility: Walk 150 feet: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.Used to calculate change in mobility
value for the LTCH Function Mobility QM.
GG0170K2
Mobility: Walk 150 feet: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
For Key, see page 17 of this file
N/A
R
N/A
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 9
Item No.
Description
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
Y
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Used to calculate change in mobility value for
the LTCH Function Mobility QM.
Mobility: Does the patient use a
wheelchair/scooter?
R
N/A
N/A
N/A
Item added to reduce burden. If GG0170Q=0,
skip to H0350 Bladder Continence.
Y
GG0170R1
Mobility: Wheel 50 feet with two turns:
Admission Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170R2
Mobility: Wheel 50 feet with two turns:
Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0170R3
Mobility: Wheel 50 feet with two turns:
Discharge Performance
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170RR1
Mobility: Indicate the type of
wheelchair/scooter used
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170RR3
Mobility: Indicate the type of
wheelchair/scooter used.
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170S1
Mobility: Wheel 150 feet: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170S2
Mobility: Wheel 150 feet: Discharge Goal
R
N/A
N/A
N/A
Reporting at least 1 or more goals provides
documentation that function is included in the
patient's care plan.
Y
GG0170S3
Mobility: Wheel 150 feet: Discharge
Performance
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
GG0170K3
Mobility: Walk 150 feet: Discharge
Performance
GG0170Q1
For Key, see page 17 of this file
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 10
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Mobility: Indicate the type of
wheelchair/scooter used: Admission
Performance
R
N/A
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
Mobility: Indicate the type of
wheelchair/scooter used: Discharge
Performance
N/A
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Y
Y
Item No.
Description
GG0170SS1
GG0170SS3
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
H0350
Bladder Continence
R
R
N/A
N/A
Standardized assessment data required for
submission as part of the Function Process
QM.
Covariate for Function Mobility QM.
H0400
Bowel Continence
R
N/A
N/A
N/A
Part of covariate calculation for PU measure
N
I0050
Indicate the patient's primary medical
condition category
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I0050A
Indicate the patient's primary medical
condition category (ICD): Other medical
condition
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I0101
Comorbidities and Co-existing Conditions:
Severe and Metastatic Cancers
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I0900
Comorbidities and Co-existing Conditions:
Peripheral Vascular Disease (PVD) or
Peripheral Arterial Disease (PAD)
R
N/A
N/A
N/A
Part of covariate calculation for PU measure.
N
I1501
Comorbidities and Co-existing Conditions:
Chronic Kidney Disease, Stage 5
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I1502
Comorbidities and Co-existing Conditions:
Acute Renal Failure
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I2101
Comorbidities and Co-existing Conditions:
Septicemia, Sepsis, Systemic Inflammatory
Response Syndrome/Shock
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
For Key, see page 17 of this file
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 11
Admission
Planned
Discharge
Unplanned
Discharge
Expired
I2600
Comorbidities and Co-existing Conditions:
Central Nervous System Infections,
Opportunistic Infections, Bone/Joint/Muscle
Infections/Necrosis
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I2900
Comorbidities and Co-existing Conditions:
Diabetes Mellitus (DM)
R
N/A
N/A
N/A
Part of covariate calculation for PU measure.
Covariate for LTCH Function Mobility QM.
N
I4100
Comorbidities and Co-existing Conditions:
Major Lower Limb Amputation
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I4501
Comorbidities and Co-existing Conditions:
Stroke
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I4801
Comorbidities and Co-existing Conditions:
Dementia
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I4900
Comorbidities and Co-existing Conditions:
Hemiplegia or Hemiparesis
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I5000
Comorbidities and Co-existing Conditions:
Paraplegia
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I5101
Comorbidities and Co-existing Conditions:
Complete Tetraplegia
R
N/A
N/A
N/A
Exclusion for the LTCH Function Mobility
QM.
Covariate for Function Mobility QM.
Y
I5102
Comorbidities and Co-existing Conditions:
Incomplete Tetraplegia
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I5110
Comorbidities and Co-existing Conditions:
Other Spinal Cord Disorder/Injury
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
I5200
Comorbidities and Co-existing Conditions:
Multiple Sclerosis (MS)
R
N/A
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
Y
I5250
Comorbidities and Co-existing Conditions:
Huntington's Disease
R
N/A
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
Y
I5300
Comorbidities and Co-existing Conditions:
Parkinson's Disease
R
N/A
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
Y
Item No.
Description
For Key, see page 17 of this file
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 12
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Comorbidities and Co-existing Conditions:
Amyotrophic Lateral Sclerosis
R
N/A
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
Y
I5460
Comorbidities and Co-existing Conditions:
Locked-In State
R
N/A
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
Y
I5470
Comorbidities and Co-existing Conditions:
Severe Anoxic Brain Damage, Cerebral
Edema, or Compression of Brain
R
N/A
N/A
N/A
Exclusion criterion for the LTCH Function
Mobility QM.
Y
I5601
Comorbidities and Co-existing Conditions:
Malnutrition (protein or calorie)
R
N/A
N/A
N/A
Part of covariate calculation for LTCH
Mobility QM.
N
I5602
Comorbidities and Co-existing Conditions: At
risk for Malnutrition
R
N/A
N/A
N/A
Part of covariate calculation for LTCH
Mobility QM.
Y
17900
Comorbidities and Co-existing Conditions:
None of the above
R
N/A
N/A
N/A
None of the comorbidity covariates apply to
this patient.
N
J1800
Any Falls Since Admission
N/A
R
R
R
Part of numerator calculation for Falls
measure.
Y
J1900A
Number of Falls Since Admission - No Injury
N/A
RIAV
RIAV
RIAV
Part of numerator calculation for Falls
measure.
Y
J1900B
Number of Falls Since Admission - Injury
(except major)
N/A
RIAV
RIAV
RIAV
Part of numerator calculation for Falls
measure.
Y
J1900C
Number of Falls Since Admission - Major
injury
N/A
R
R
R
Part of numerator calculation for Falls
measure.
Y
K0200A
Height (in inches)
R
N/A
N/A
N/A
Part of covariate calculation for PU measure.
N
K0200B
Weight (in pounds)
R
N/A
N/A
N/A
Part of covariate calculation for PU measure.
N
M0210
Unhealed Pressure Ulcer(s): Does this patient
have one or more unhealed pressure ulcer(s)
at Stage 1 or higher?
R
R
R
N/A
System cannot accept record without
response.
N
M0300A
Stage 1: Number of Stage 1 pressure ulcers
V
V
V
N/A
—
N
M0300B1
Stage 2: Number of Stage 2 pressure ulcers
R
R
R
N/A
Used for PU Measure consistency checks.
N
Item No.
Description
I5450
For Key, see page 17 of this file
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 13
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Stage 2: Number of these Stage 2 pressure
ulcers that were present upon admission
N/A
R
R
N/A
—
N
M0300C1
Stage 3: Number of Stage 3 pressure ulcers
R
R
R
N/A
Used for PU Measure consistency checks.
N
M0300C2
Stage 3: Number of these Stage 3 pressure
ulcers that were present upon admission
N/A
R
R
N/A
—
N
M0300D1
Stage 4: Number of Stage 4 pressure ulcers
R
R
R
N/A
Used for PU Measure consistency checks.
N
M0300D2
Stage 4: Number of these Stage 4 pressure
ulcers that were present upon admission
N/A
R
R
N/A
—
N
M0300E1
Unstageable - Non-removable dressing:
Number of unstageable pressure ulcers due to
non-removable dressing/device
R
V
V
N/A
—
N
M0300E2
Unstageable - Non-removable dressing:
Number of these unstageable pressure ulcers
that were present upon admission
N/A
V
V
N/A
—
N
M0300F1
Unstageable - Slough and/or eschar: Number
of unstageable pressure ulcers due to coverage
of wound bed by slough and/or eschar
R
V
V
N/A
—
N
M0300F2
Unstageable - Slough and/or eschar: Number
of these unstageable pressure ulcers that were
present upon admission
N/A
V
V
N/A
—
N
M0300G1
Unstageable - Deep tissue injury: Number of
unstageable pressure ulcers with suspected
deep tissue injury in evolution
R
V
V
N/A
—
N
M0300G2
Unstageable - Deep tissue injury: Number of
these unstageable pressure ulcers that were
present upon admission
N/A
V
V
N/A
—
N
M0800A
Worsening in Pressure Ulcer Status Since
Admission: Stage 2
N/A
R
R
N/A
Part of numerator calculation for PU measure.
N
M0800B
Worsening in Pressure Ulcer Status Since
Admission: Stage 3
N/A
R
R
N/A
Part of numerator calculation for PU measure.
N
Item No.
Description
M0300B2
For Key, see page 17 of this file
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 14
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
Worsening in Pressure Ulcer Status Since
Admission: Stage 4
N/A
R
R
N/A
Part of numerator calculation for PU measure.
N
M0800D
Worsening in Pressure Ulcer Status Since
Admission: Unstageable - Non-removable
dressing
N/A
V
V
N/A
—
Y
M0800E
Worsening in Pressure Ulcer Status Since
Admission: Unstageable - Slough and/or
eschar
N/A
V
V
N/A
—
Y
M0800F
Worsening in Pressure Ulcer Status Since
Admission: Unstageable - Deep tissue injury
N/A
V
V
N/A
—
Y
O0100F3
Special Treatments, Procedures, and
Programs: Invasive Mechanical Ventilator:
weaning
R
N/A
N/A
N/A
Inclusion criterion for the LTCH Function
Mobility QM.
Y
O0100F4
Special Treatments, Procedures, and
Programs: Invasive Mechanical Ventilator:
non-weaning
R
N/A
N/A
N/A
Inclusion criterion for the LTCH Function
Mobility QM.
Y
O0100G
Special Treatments, Procedures, and
Programs: Non-invasive Ventilator (BIPAP,
CPAP)
R
N/A
N/A
N/A
Inclusion criterion for the LTCH Function
Mobility QM.
Y
O0100J
Special Treatments, Procedures, and
Programs: Dialysis
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
O0100N
Special Treatments, Procedures, and
Programs: Total Parenteral Nutrition
R
N/A
N/A
N/A
Covariate for Function Mobility QM.
Y
O0100Z
Special Treatments, Procedures, and
Programs: None of the above
R
N/A
N/A
N/A
None of the comorbidity covariates for special
treatments, procedures, and programs apply to
this patient.
Y
O0250A
Influenza vaccine - Did patient receive
influenza vaccine in this facility for this year's
influenza vaccination season?
R
R
R
R
Part of numerator calculation for Influenza
vaccination measure.
N
Item No.
Description
M0800C
For Key, see page 17 of this file
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 15
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Influenza vaccine - Date influenza vaccine
received
RIAV
RIAV
RIAV
RIAV
Part of numerator calculation for Influenza
vaccination measure.
N
O0250C
Influenza vaccine - If influenza vaccine not
received, state reason:
R
R
R
R
Part of numerator calculation for Influenza
vaccination measure.
N
Z0400A
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400B
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400C
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400D
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400E
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400F
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400G
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Item No.
Description
O0250B
For Key, see page 17 of this file
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
New for
V3.00
Page 16
Admission
Planned
Discharge
Unplanned
Discharge
Expired
Signature of Persons Completing the
Assessment: Attestation signature, title,
sections, date
N/A
N/A
N/A
N/A
—
N
Z0400I
Attestation signature, title, sections, date
N/A
N/A
N/A
N/A
—
N
Z0400J
Attestation signature, title, sections, date
N/A
N/A
N/A
N/A
—
N
Z0400K
Attestation signature, title, sections, date
N/A
N/A
N/A
N/A
—
N
Z0400L
Attestation signature, title, sections, date
N/A
N/A
N/A
N/A
—
N
Z0500A
Attestation signature of person verifying
completion
N/A
N/A
N/A
N/A
—
N
Z0500B
LTCH CARE Data Set Completion Date
R
R
R
R
System cannot accept record without response
N
Item No.
Description
Z0400H
Rationale for Inclusion as a Required Item for
April 1, 2016 Data Collection
New for
V3.00
Key:
R: Required
RIAV: Required if information is available
V: Voluntary
N/A: Not Applicable
For Key, see page 17 of this file
Appendix A – Master List of LTCH CARE Data Set Version 3.00 Items
Page 17
| File Type | application/pdf |
| File Title | APPENDIX ALONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD & EVALUATION DATA SET, ITEM MATRIX, V3.00 - FINAL |
| Subject | APPENDIX ALONG-TERM CARE HOSPITAL CONTINUITY ASSESSMENT RECORD & EVALUATION DATA SET, ITEM MATRIX, V3.00 - FINAL |
| Author | RTI International and/or Centers for Medicaid & Medicare Service |
| File Modified | 2016-03-03 |
| File Created | 2016-03-03 |