Appendix A: Change Table

LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018
LTCH CARE Data Set V 4.00
(Note: Modifications to existing items
highlighted in yellow)

Item Set(s)
Affected

Item / Text
Affected

1.

All

N/A

Version 3.00

Version 4.00

Updated version number.

2.

All

Footer

Effective April 1, 2016

Final LTCH CARE Data Set Version 4.00,
Admission/Planned Discharge/Unplanned
Discharge/Expired - Effective July 1, 2018

Updated effective date.

3.

All

N/A

N/A

Punctuation and style revisions applicable
throughout the instrument

Punctuation and style
revisions to be consistent
with MDS and IRF-PAI.

4.

All

Section
Headings
and Titles

White and gray font

Black and bold font

Updated font formatting
for better contrast.

5.

Admission

A1802

A1802. Admitted From
09. ID/DD facility

A1802. Admitted From
09. Intellectually Disabled/Developmentally
Disabled (ID/DD) facility

Spelled out code 09 for
clarity.

6.

Admission,
Planned
Discharge,
Unplanned
Discharge,
Expired

A1400

A1400. Payer Information
K. No payor source

A1400. Payer Information
K. No payer source

Revised spelling for
consistency.

7.

Planned
Discharge,
Unplanned
Discharge

A2110

A2110. Discharge Location
09. ID/DD facility

A2110. Discharge Location
09. Intellectually Disabled/Developmentally
Disabled (ID/DD) facility

Spelled out code 09 for
clarity.

8.

Planned
Discharge

A2500

A2500. Program Interruption(s)
Program Interruptions
0. No  Skip to B0100. Comatose
1. Yes  Continue to A2510. Number of
Program Interruptions During This Stay
in This Facility

N/A – delete item

Deleted to reduce
provider burden.

#

LTCH CARE Data Set V 3.00

Rationale for
Change / Comments

Page 1 of 21

LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018
LTCH CARE Data Set V 4.00

Item Set(s)
Affected

Item / Text
Affected

9.

Unplanned
Discharge

A2500

A2500. Program Interruption(s)
Program Interruptions
0. No  Skip to C1610. Signs and
Symptoms of Delirium (from CAM©)
1. Yes  Continue to A2510. Number of
Program Interruptions During This Stay
in This Facility

N/A – delete item

Deleted to reduce
provider burden.

10.

Planned
Discharge,
Unplanned
Discharge

A2510

A2510. Number of Program
Interruptions During This Stay in This
Facility. Code only if A2500 equals to 1.

N/A – delete item

Deleted to reduce
provider burden.

11.

Planned
Discharge,
Unplanned
Discharge

A2525

A2525. Program Interruption Dates.
Code only if A2510 is greater than or
equal to 01.

N/A – delete item

Deleted to reduce
provider burden.

#

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

A1. First Interruption Start Date
A2. First Interruption End Date
B1. Second Interruption Start Date
Code only if A2510 is greater than 01.
B2. Second Interruption End Date
Code only if A2510 is greater than 01.
C1. Third Interruption Start Date
Code only if A2510 is greater than 02.
C2. Third Interruption End Date
Code only if A2510 is greater than 02.
D1. Fourth Interruption Start Date
Code only if A2510 is greater than 03.
D2. Fourth Interruption End Date
Code only if A2510 is greater than 03.
E1. Fifth Interruption Start Date
Code only if A2510 is greater than 04.
E2. Fifth Interruption End Date
Code only if A2510 is greater than 04.
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LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018

#
12.

13.

Item Set(s)
Affected

Item / Text
Affected

Admission,
Planned
Discharge

BB0800

Admission

GG0100

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
BB0800. Understanding Verbal Content
(3-day assessment period)
Understanding Verbal Content (with
hearing aid or device, if used and
excluding language barriers)
4. Understands: Clear comprehension
without cues or repetitions
3. Usually Understands: Understands
most conversations, but misses some
part/intent of message. Requires cues at
times to understand
2. Sometimes Understands:
Understands only basic conversations or
simple, direct phrases. Frequently
requires cues to understand
1. Rarely/Never Understands
GG0100. Prior Functioning: Everyday
Activities. Indicate the patient's usual
ability with everyday activities prior to
the current illness, exacerbation, or
injury.
3. Independent - Patient completed the
activities by him/herself, with or
without an assistive device, with no
assistance from a helper.
2. Needed Some Help - Patient needed
partial assistance from another person
to complete activities.
1. Dependent - A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

BB0800. Understanding Verbal and NonVerbal Content (3-day assessment period)
Understanding Verbal and Non-Verbal
Content (with hearing aid or device, if used,
and excluding language barriers)
4. Understands: Clear comprehension without
cues or repetitions
3. Usually Understands: Understands most
conversations, but misses some part/intent of
message. Requires cues at times to
understand
2. Sometimes Understands: Understands only
basic conversations or simple, direct phrases.
Frequently requires cues to understand
1. Rarely/Never Understands

Added clarification that
Non-Verbal Content can
also be considered.

GG0100. Prior Functioning: Everyday
Activities. Indicate the patient's usual ability
with everyday activities prior to the current
illness, exacerbation, or injury.
Coding:
3. Independent - Patient completed the
activities by him/herself, with or without an
assistive device, with no assistance from a
helper.
2. Needed Some Help - Patient needed partial
assistance from another person to complete
activities.
1. Dependent - A helper completed the
activities for the patient.
8. Unknown
9. Not Applicable

Added “Coding” to
GG0100 instructions for
consistency.

Added comma for
clarification.

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LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018

#
14.

Item Set(s)
Affected

Item / Text
Affected

Admission

GG0110

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

GG0110. Prior Device Use. Indicate
devices and aids used by the patient
prior to the current illness,
exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices
and aids used by the patient prior to the
current illness, exacerbation, or injury.

Check all that apply
A. Manual wheelchair
B. Motorized wheelchair or scooter
C. Mechanical lift
Z. None of the above

Check all that apply
A. Manual wheelchair
B. Motorized wheelchair and/or scooter
C. Mechanical lift
Z. None of the above

Rationale for
Change / Comments
Added “and/” for
clarification.

15.

Admission

GG0130
Discharge
goal coding

Code the patient's usual performance
at admission for each activity using the
6-point scale. If activity was not
attempted at admission, code the
reason. Code the patient's discharge
goal(s) using the 6-point scale. Do not
use codes 07, 09, or 88 to code
discharge goal(s).

Code the patient's usual performance at
admission for each activity using the 6-point
scale. If activity was not attempted at
admission, code the reason. Code the
patient's discharge goal(s) using the 6-point
scale. Use of codes 07, 09, 10 or 88 is
permissible to code discharge goal(s).

Added instructions
indicating that the activity
not attempted codes may
be used to code goal
items.

16.

Admission,
Planned
Discharge

GG0130
Coding
options

From 6-point scale

From 6-point scale

05. Setup or clean-up assistance Helper SETS UP or CLEANS UP; patient
completes activity. Helper assists only
prior to or following the activity.

05. Setup or clean-up assistance - Helper sets
up or cleans up; patient completes activity.
Helper assists only prior to or following the
activity.

Added “contact guard”
and changed “or” to
“and/or” for clarification
in code 04. Removed
capitalization from code
05.

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.

04. Supervision or touching assistance Helper provides verbal cues and/or
touching/steadying and/or contact guard
assistance as patient completes activity.
Assistance may be provided throughout the
activity or intermittently.
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#
17.

Item Set(s)
Affected

Item / Text
Affected

Admission,
Planned
Discharge

GG0130
Coding
options

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

If activity was not attempted, code the
reason:

If activity was not attempted, code reason:

Added definition of 09 for
clarification.

07. Patient refused
09. Not applicable
88. Not attempted due to medical
condition or safety concerns

07. Patient refused
09. Not applicable – Not attempted and the
patient did not perform this activity prior to
the current illness, exacerbation, or injury.
10. Not attempted due to environmental
limitations (e.g. lack of equipment, weather
constraints)
88. Not attempted due to medical condition
or safety concerns

Added new code to allow
reporting of
environmental limitations.

18.

Admission,
Planned
Discharge

GG0130A

A. Eating: The ability to use suitable
utensils to bring food to the mouth and
swallow food once the meal is
presented on a table/tray. Includes
modified food consistency.

A. Eating: The ability to use suitable utensils
to bring food and/or liquid to the mouth and
swallow food and/or liquid once the meal is
placed before the patient.

Revised wording of the
item definition for
clarification.

19.

Admission,
Planned
Discharge

GG0130B

B. Oral hygiene: The ability to use
suitable items to clean teeth. [Dentures
(if applicable): The ability to remove and
replace dentures from and to the
mouth, and manage equipment for
soaking and rinsing them.]

B. Oral hygiene: The ability to use suitable
items to clean teeth. Dentures (if applicable):
The ability to insert and remove dentures into
and from the mouth, and manage denture
soaking and rinsing with use of equipment.

Revised wording of the
item definition for
clarification.

20.

Admission,
Planned
Discharge

GG0130C

C. Toileting hygiene: The ability to
maintain perineal hygiene, adjust
clothes before and after using the toilet,
commode, bedpan or urinal. If
managing an ostomy, include wiping the
opening but not managing equipment.

C. Toileting hygiene: The ability to maintain
perineal hygiene, adjust clothes before and
after voiding or having a bowel movement. If
managing an ostomy, include wiping the
opening but not managing equipment.

Revised wording of the
item definition for
clarification.

Page 5 of 21

LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018
LTCH CARE Data Set V 4.00

Item Set(s)
Affected

Item / Text
Affected

21.

Admission

GG0170
Discharge
goal coding

Code the patient's usual performance
at admission for each activity using the
6-point scale. If activity was not
attempted at admission, code the
reason. Code the patient's discharge
goal(s) using the 6-point scale. Do not
use codes 07, 09, or 88 to code
discharge goal(s).

Code the patient's usual performance at
admission for each activity using the 6-point
scale. If activity was not attempted at
admission, code the reason. Code the
patient's discharge goal(s) using the 6-point
scale. Use of codes 07, 09, 10 or 88 is
permissible to code discharge goal(s).

Added instructions
indicating that the activity
not attempted codes may
be used to code goal
items.

22.

Admission,
Planned
Discharge

GG0170
Coding
option

From 6-point scale

From 6-point scale

05. Setup or clean-up assistance Helper SETS UP or CLEANS UP; patient
completes activity. Helper assists only
prior to or following the activity.

05. Setup or clean-up assistance - Helper sets
up or cleans up; patient completes activity.
Helper assists only prior to or following the
activity.

Added “contact guard”
and changed “or” to
“and/or” for clarification
in code 04.

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.

04. Supervision or touching assistance Helper provides verbal cues and/or
touching/steadying and/or contact guard
assistance as patient completes activity.
Assistance may be provided throughout the
activity or intermittently.

#

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

Removed capitalization
from code 05.

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LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018

#
23.

Item Set(s)
Affected

Item / Text
Affected

Admission,
Planned
Discharge

GG0170
Coding
option

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
If activity was not attempted, code the
reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical
condition or safety concerns

(Note: Modifications to existing items highlighted
in yellow)

If activity was not attempted, code reason:
07. Patient refused
09. Not applicable – Not attempted and the
patient did not perform this activity prior to
the current illness, exacerbation, or injury.
10. Not attempted due to environmental
limitations (e.g. lack of equipment, weather
constraints)
88. Not attempted due to medical condition
or safety concerns

Rationale for
Change / Comments
Added definition of 09 for
clarification.
Added new code to allow
reporting of
environmental limitations.

24.

Admission,
Planned
Discharge

GG0170A

A. Roll left and right: The ability to roll
from lying on back to left and right side,
and return to lying on back.

A. Roll left and right: The ability to roll from
lying on back to left and right side, and return
to lying on back on the bed.

Added “on the bed” for
clarification.

25.

Admission,
Planned
Discharge

GG0170C

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, and with no
back support.

C. Lying to sitting on side of bed: The ability
to move from lying on the back to sitting on
the side of the bed with feet flat on the floor,
and with no back support.

Removed “safely.” The
coding instructions refer
to safe performance,
which applies to all selfcare and mobility items.

26.

Admission,
Planned
Discharge

GG0170D

D. Sit to stand: The ability to safely
come to a standing position from sitting
in a chair or on the side of the bed.

D. Sit to stand: The ability to come to a
standing position from sitting in a chair,
wheelchair, or on the side of the bed.

Removed “safely.” The
coding instructions refer
to safe performance,
which applies to all selfcare and mobility items.
Added “wheelchair” for
clarification.

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LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018
LTCH CARE Data Set V 4.00

Item Set(s)
Affected

Item / Text
Affected

27.

Admission,
Planned
Discharge

GG0170E

E. Chair/bed-to-chair transfer: The
ability to safely transfer to and from a
bed to a chair (or wheelchair).

E. Chair/bed-to-chair transfer: The ability to
transfer to and from a bed to a chair (or
wheelchair).

Removed “safely.” The
coding instructions refer
to safe performance,
which applies to all selfcare and mobility items.

28.

Admission,
Planned
Discharge

GG0170F

F. Toilet transfer: The ability to safely
get on and off a toilet or commode.

F. Toilet transfer: The ability to get on and off
a toilet or commode.

Removed “safely.” The
coding instructions refer
to safe performance,
which applies to all selfcare and mobility items.

29.

Admission

GG0170H1

H1. Does the patient walk?
0. No, and walking goal is not clinically
indicated  Skip to GG0170Q1. Does
the patient use a wheelchair/scooter?
1. No, and walking goal is clinically
indicated  Code the patient's
Discharge Goal(s) for items GG0170I, J,
and K. For Admission Performance, skip
to GG0170Q1. Does the patient use a
wheelchair/ scooter?
2. Yes  Continue to GG0170I. Walk 10
feet

N/A – delete item

The skip pattern is
associated with the item
Walk 10 feet.

30.

Planned
Discharge

GG0170H3

H3. Does the patient walk?
0. No  Skip to GG0170Q3. Does the
patient use wheelchair/scooter?
2. Yes  Continue to GG0170I. Walk 10
feet

N/A – delete item

The skip pattern is
associated with the item
Walk 10 feet.

#

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

Page 8 of 21

LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018

#
31.

32.

Item Set(s)
Affected

Item / Text
Affected

Admission

GG0170I

Planned
Discharge

GG0170I

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
I. Walk 10 feet: Once standing, the
ability to walk at least 10 feet in a room,
corridor or similar space.

I. Walk 10 feet: Once standing, the
ability to walk at least 10 feet in a room,
corridor or similar space.

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

I. Walk 10 feet: Once standing, the ability to
walk at least 10 feet in a room, corridor, or
similar space.
If admission performance is coded 07, 09, 10,
or 88  Skip to GG0170Q1, Does the patient
use a wheelchair and/or scooter?

Added skip pattern that
was previously associated
with GG0170H1.

I. Walk 10 feet: Once standing, the ability to
walk at least 10 feet in a room, corridor, or
similar space.
If discharge performance is coded 07, 09, 10,
or 88  Skip to GG0170Q3, Does the patient
use a wheelchair and/or scooter?

Added skip pattern that
was previously associated
with GG0170H3.

Added comma for
clarification.

Added comma for
clarification.

33.

Admission

GG0170Q1

Q1. Does the patient use a
wheelchair/scooter?
0. No  Skip to H0350. Bladder
Continence
1. Yes  Continue to GG0170R. Wheel
50 feet with two turns

Q1. Does the patient use a wheelchair and/or
scooter?
0. No  Skip to H0350, Bladder Continence
1. Yes  Continue to GG0170R, Wheel 50 feet
with two turns

Added for clarification.

34.

Planned
Discharge

GG0170Q3

Q3. Does the patient use a
wheelchair/scooter?
0. No  Skip to H0350. Bladder
Continence
1. Yes  Continue to GG0170R. Wheel
50 feet with two turns

Q3. Does the patient use a wheelchair and/or
scooter?
0. No  Skip to H0350, Bladder Continence
1. Yes  Continue to GG0170R, Wheel 50 feet
with two turns

Added for clarification.

Page 9 of 21

LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018
LTCH CARE Data Set V 4.00

Item Set(s)
Affected

Item / Text
Affected

35.

Admission

GG0170RR1

RR1. Indicate the type of
wheelchair/scooter used.
1. Manual
2. Motorized

RR1. Indicate the type of wheelchair or
scooter used.
1. Manual
2. Motorized

Added for clarification.

36.

Planned
Discharge

GG0170RR3

RR3. Indicate the type of
wheelchair/scooter used.
1. Manual
2. Motorized

RR3. Indicate the type of wheelchair or
scooter used.
1. Manual
2. Motorized

Added for clarification.

37.

Admission

GG0170SS1

SS1. Indicate the type of
wheelchair/scooter used.
1. Manual
2. Motorized

SS1. Indicate the type of wheelchair or
scooter used.
1. Manual
2. Motorized

Added for clarification.

38.

Planned
Discharge

GG0170SS3

SS3. Indicate the type of
wheelchair/scooter used.
1. Manual
2. Motorized

SS3. Indicate the type of wheelchair or
scooter used.
1. Manual
2. Motorized

Added for clarification.

39.

Admission

I0050

5. Other medical condition If “other
medical condition”, enter the ICD code
in the boxes. I0050A.

5. Other medical condition If “other medical
condition,” enter the ICD code in the boxes.
I0050A.

Moved comma

#

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

Page 10 of 21

LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018

#
40.

Item Set(s)
Affected

Item / Text
Affected

Admission

I0103
I0104
I0605
I5455
I5480
I7100
I7101
I7102
I7103
I7104

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
N/A – new items

(Note: Modifications to existing items highlighted
in yellow)

Comorbidities and Co-existing Conditions
↓ Check all that apply
I0103. Metastatic Cancer
I0104. Severe Cancer
I0605. Severe Left Systolic/Ventricular
Dysfunction (known ejection fraction ≤ 30%)
I5455. Other Progressive Neuromuscular
Disease
I5480. Other Severe Neurological Injury,
Disease, or Dysfunction
Post-Transplant
I7100. Lung Transplant
I7101. Heart Transplant
I7102. Liver Transplant
I7103. Kidney Transplant
I7104. Bone Marrow Transplant
N/A – delete item

41.

Admission

I0101

I0101. Severe and Metastatic Cancer

42.

Planned
Discharge

J1800

J1800. Any Falls Since Admission
Has the patient had any falls since
admission?

J1800. Any Falls Since Admission
Has the patient had any falls since admission?

0. No  Skip to M0210. Unhealed
Pressure Ulcer(s)
1. Yes  Continue to J1900. Number of
Falls Since Admission

0. No  Skip to M0210, Unhealed Pressure
Ulcers/Injuries
1. Yes  Continue to J1900, Number of Falls
Since Admission

Rationale for
Change / Comments
New items added to
collect data for the
ventilator weaning quality
measures.

I0101 will be replaced by
I0103 and I0104.
Revised to correct skip
pattern.

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LTCH CARE Data Set Version 4.00 Change Table - Effective July 1, 2018

#
43.

44.

45.

Item Set(s)
Affected

Item / Text
Affected

Unplanned
Discharge

J1800

Expired

Admission,
Planned
Discharge,
Unplanned
Discharge

J1800

Section M
heading

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
J1800. Any Falls Since Admission
Has the patient had any falls since
admission?

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

J1800. Any Falls Since Admission
Has the patient had any falls since admission?

Revised to correct skip
pattern.

0. No  Skip to M0210. Unhealed
Pressure Ulcer(s)
1. Yes  Continue to J1900. Number of
Falls Since Admission
J1800. Any Falls Since Admission
Has the patient had any falls since
admission?

0. No  Skip to M0210, Unhealed Pressure
Ulcers/Injuries
1. Yes  Continue to J1900, Number of Falls
Since Admission
J1800. Any Falls Since Admission
Has the patient had any falls since admission?

Revised to correct skip
pattern.

0. No  Skip to O0250. Influenza
Vaccine
1. Yes  Continue to J1900. Number of
Falls Since Admission
Report based on highest stage of
existing ulcer(s) at its worst; do not
“reverse” stage

0. No  Skip to N2005, Medication
Intervention
1. Yes  Continue to J1900, Number of Falls
Since Admission
Report based on highest stage of existing
ulcers/injuries at their worst; do not
“reverse” stage

Added the term “injuries”
to be inclusive of updated
terminology supported by
the National Pressure
Ulcer Advisory Panel
(NPUAP).

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#
46.

47.

48.

Item Set(s)
Affected

Item / Text
Affected

Admission

M0210

Planned
Discharge,
Unplanned
Discharge

Admission,
Planned
Discharge,
Unplanned
Discharge

M0210

M0300

LTCH CARE Data Set V 4.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

M0210. Unhealed Pressure Ulcer(s)
Does this patient have one or more
unhealed pressure ulcer(s) at Stage 1 or
higher?
0. No  Skip to O0100. Special
Treatments, Procedures, and Programs
1. Yes  Continue to M0300. Current
Number of Unhealed Pressure Ulcers at
Each Stage

M0210. Unhealed Pressure Ulcers/Injuries
Does this patient have one or more unhealed
pressure ulcers/injuries?

Deleted text to clarify.
Added the term “injury”
to be inclusive of updated
terminology supported by
NPUAP.

M0210. Unhealed Pressure Ulcer(s)
Does this patient have one or more
unhealed pressure ulcer(s) at Stage 1 or
higher?
0. No  Skip to O0100. Special
Treatments, Procedures, and Programs
1. Yes  Continue to M0300. Current
Number of Unhealed Pressure Ulcers at
Each Stage

M0210. Unhealed Pressure Ulcers/Injuries
Does this patient have one or more unhealed
pressure ulcers/injuries?
0. No  Skip to N2005, Medication
Intervention
1. Yes  Continue to M0300, Current Number
of Unhealed Pressure Ulcers/Injuries at Each
Stage

M0300. Current Number of Unhealed
Pressure Ulcers at Each Stage

M0300. Current Number of Unhealed
Pressure Ulcers/Injuries at Each Stage

LTCH CARE Data Set V 3.00

0. No  Skip to N2001, Drug Regimen Review
1. Yes  Continue to M0300, Current Number
of Unhealed Pressure Ulcers/Injuries at Each
Stage

Deleted text to clarify.
Added the term “injuries”
to be inclusive of updated
terminology supported by
NPUAP.

Added the term “injuries”
to be inclusive of updated
terminology supported by
NPUAP.

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LTCH CARE Data Set V 4.00

Item Set(s)
Affected

Item / Text
Affected

49.

Admission,
Planned
Discharge,
Unplanned
Discharge

M0300A

Number of Stage 1 pressure ulcers

1. Number of Stage 1 pressure injuries

Added the number one to
be consistent with other
items in the section.
Replaced the term
“ulcers” with “injuries” as
the term “injuries”
indicates intact skin which
better aligns with criteria
for Stage 1.

50.

Planned
Discharge,
Unplanned
Discharge

M0300D1

D1. Number of Stage 4 pressure ulcers If 0  Skip to M0300E. Unstageable Non-removable dressing

D1. Number of Stage 4 pressure ulcers - If 0
 Skip to M0300E, Unstageable - Nonremovable dressing/device

Added the word “device”
for clarity.

51.

Admission

M0300E
M0300E1

E. Unstageable - Non-removable
dressing: Known but not stageable due
to non-removable dressing/device

E. Unstageable - Non-removable
dressing/device: Known but not stageable due
to non-removable dressing/device

Added the word “device”
for clarity.

1. Number of unstageable pressure
ulcers due to non-removable
dressing/device

1. Number of unstageable pressure
ulcers/injuries due to non-removable
dressing/device

#

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

Added the term “injuries”
to be inclusive of updated
terminology supported by
NPUAP.

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#
52.

53.

Item Set(s)
Affected

Item / Text
Affected

Planned
Discharge,
Unplanned
Discharge

M0300E
M0300E2

Admission

M0300G
M0300G1

LTCH CARE Data Set V 4.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

E. Unstageable - Non-removable
dressing: Known but not stageable due
to non-removable dressing/device

E. Unstageable - Non-removable
dressing/device: Known but not stageable due
to non-removable dressing/device

Added the word “device”
for clarity.

1. Number of unstageable pressure
ulcers due to non-removable
dressing/device - If 0 Skip to M0300F.
Unstageable - Slough and/or eschar

1. Number of unstageable pressure
ulcers/injuries due to non-removable
dressing/device - If 0  Skip to M0300F,
Unstageable - Slough and/or eschar

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

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

G. Unstageable - Deep tissue injury:
Suspected deep tissue injury in
evolution.

G. Unstageable - Deep tissue injury

1. Number of unstageable pressure
ulcers with suspected deep tissue
injury in evolution

1. Number of unstageable pressure injuries
presenting as deep tissue injury

LTCH CARE Data Set V 3.00

Added the term “injuries”
to be inclusive of updated
terminology supported by
NPUAP.

Removed the term
“suspected deep tissue
injury in evolution” and
replaced with “deep
tissue injury” to be
consistent with updated
NPUAP terminology.

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#
54.

Item Set(s)
Affected

Item / Text
Affected

Planned
Discharge,
Unplanned
Discharge

M0300G
M0300G1
M0300G2

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
G. Unstageable - Deep tissue injury:
Suspected deep tissue injury in
evolution.

G. Unstageable - Deep tissue injury

1. Number of unstageable pressure
ulcers with suspected deep tissue
injury in evolution - If 0 Skip to
M0800. Worsening in Pressure Ulcer
Status Since Admission

1. Number of unstageable pressure injuries
presenting as deep tissue injury - If 0  Skip
to N2005, Medication Intervention

2. Number of these unstageable
pressure ulcers that were present upon
admission - enter how many were
noted at the time of admission
55.

Planned
Discharge,
Unplanned
Discharge

M0800

(Note: Modifications to existing items highlighted
in yellow)

M0800. Worsening in Pressure Ulcer
Status Since Admission
Indicate the number of current pressure
ulcers that were not present or were at
a lesser stage on admission. If no
current pressure ulcer at a given stage,
enter 0
A. Stage 2
B. Stage 3
C. Stage 4
D. Unstageable - Non-removable
dressing
E. Unstageable - Slough and/or eschar
F. Unstageable - Deep tissue injury

Rationale for
Change / Comments
Removed the term
“suspected deep tissue
injury in evolution” and
replaced with “deep
tissue injury” to be
consistent with updated
NPUAP terminology.

2. Number of these unstageable pressure
injuries that were present upon admission enter how many were noted at the time of
admission
N/A – delete items

Deleted to reduce
provider burden.

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LTCH CARE Data Set V 4.00

Item Set(s)
Affected

Item / Text
Affected

56.

Admission,
Planned
Discharge,
Unplanned
Discharge,
Expired

Section N

N/A – new section

Section N. Medications

New section added on
admission and discharge
to accommodate the drug
regimen review quality
measure items N2001,
N2003, and N2005.

57.

Admission

N2001

N/A – new item

N2001. Drug Regimen Review
Did a complete drug regimen review identify
potential clinically significant medication
issues?

New items added to
collect data for the drug
regimen review quality
measure.

#

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

0. No - No issues found during review  Skip
to O0100, Special Treatments, Procedures, and
Programs
1. Yes - Issues found during review 
Continue to N2003, Medication Follow-up
9. NA - Patient is not taking any
medications Skip to O0100, Special
Treatments, Procedures, and Programs
58.

Admission

N2003

N/A – new item

N2003. Medication Follow-up
Did the facility contact a physician (or
physician-designee) by midnight of the next
calendar day and complete prescribed/
recommended actions in response to the
identified potential clinically significant
medication issues?

New item added to collect
data for the drug regimen
review quality measure.

0. No
1. Yes

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#
59.

Item Set(s)
Affected

Item / Text
Affected

Planned
Discharge,
Unplanned
Discharge,
Expired

N2005

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
N/A – new item

(Note: Modifications to existing items highlighted
in yellow)

N2005. Medication Intervention
Did the facility contact and complete
physician (or physician-designee) prescribed/
recommended actions by midnight of the
next calendar day each time potential
clinically significant medication issues were
identified since the admission?

Rationale for
Change / Comments
New item added to collect
data for the drug regimen
review quality measure.

0. No
1. Yes
9. NA - There were no potential clinically
significant medication issues identified since
admission or patient is not taking any
medications
60.

Admission

O0100F3
O0100F4

O0100F3. Invasive Mechanical
Ventilator: weaning
O0100F4. Invasive Mechanical
Ventilator: non-weaning

N/A – delete items

Invasive mechanical
ventilation, whether
weaning or non-weaning
will now be assessed
using data collected as
part of the ventilator
weaning quality measures
(including O0150 and
O0200).

61.

Admission

O0100H
O0100H2a

N/A – new item

H. IV Medications (if checked, please specify
below)

New item added to collect
data for the ventilator
weaning quality
measures.

H2a. Vasoactive medications (i.e.,
continuous infusions of vasopressors
or inotropes)

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#
62.

Item Set(s)
Affected

Item / Text
Affected

Admission

O0150
O0150A
O0150B
O0150C
O0150D
O0150E

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
N/A – new items

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

O0150. Spontaneous Breathing Trial (SBT)
(including Tracheostomy Collar or Continuous
Positive Airway Pressure (CPAP) Breathing
Trial) by Day 2 of LTCH Stay

New items added to
collect data for the
ventilator weaning quality
measures.

A. Invasive Mechanical Ventilation Support
upon Admission to the LTCH
0. No, not on invasive mechanical ventilation
support  Skip to O0250, Influenza Vaccine
1. Yes, weaning  Continue to O0150B,
Assessed for readiness for SBT by Day 2 of the
LTCH stay
2. Yes, non-weaning  Skip to O0250,
Influenza Vaccine
(continued)

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#

Item Set(s)
Affected

Item / Text
Affected

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00

(Note: Modifications to existing items highlighted
in yellow)

Rationale for
Change / Comments

B. Assessed for readiness for SBT by day 2 of
the LTCH stay (Note: Day 2=Date of Admission
to the LTCH (Day 1) + 1 calendar day)
0. No  Skip to O0250, Influenza Vaccine
1. Yes  Continue to O0150C, Deemed
medically ready for SBT by Day 2 of the LTCH
stay
C. Deemed medically ready for SBT by day 2
of the LTCH stay
0. No  Continue to O0150D, Is there
documentation of reason(s) in the patient's
medical record that the patient was deemed
medically unready for SBT by day 2 of the LTCH
stay?
1. Yes  Continue to O0150E, SBT performed
by day 2 of the LTCH stay
D. Is there documentation of reason(s) in the
patient’s medical record that the patient was
deemed medically unready for SBT by day 2
of the LTCH stay?
0. No  Skip to O0250, Influenza Vaccine
1. Yes  Skip to O0250, Influenza Vaccine
E. SBT performed by day 2 of the LTCH stay
0. No
1. Yes

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#
63.

Item Set(s)
Affected

Item / Text
Affected

Planned
Discharge,
Unplanned
Discharge

O0200
O0200A

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 3.00
N/A – new items

(Note: Modifications to existing items highlighted
in yellow)

O0200. Ventilator Liberation Rate
A. Invasive Mechanical Ventilator: Liberation
Status at Discharge

Rationale for
Change / Comments
New items added to
collect data for the
ventilator weaning quality
measures.

0. Not fully liberated at discharge (i.e., patient
required partial or full invasive mechanical
ventilation support within 2 calendar days
prior to discharge)
1. Fully liberated at discharge (i.e., patient did
not require any invasive mechanical
ventilation support for at least 2 consecutive
calendar days immediately prior to discharge)
9. NA (code only if the patient was nonweaning or not ventilated on admission
[O0150A=2 or 0 on Admission Assessment])

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