Appendix A: Change Table

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020

#
1.

Item Set(s)
Affected
All

Item / Text
Affected
N/A

2.

All

Footer

3.

Admission,
Planned
Discharge,
Unplanned
Discharge,
Expired

A1000

4.

Admission

A1005

LTCH CARE Data Set V 4.00
Version 4.00
Final LTCH CARE Data Set Version 4.00,
Admission/Planned Discharge/ Unplanned
Discharge/Expired - Effective July 1, 2018
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
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
Version 5.00
Proposed LTCH CARE Data Set Version 5.00,
Admission/Planned Discharge/Unplanned
Discharge/Expired - Effective October 1, 2020
N/A – delete item

A1005. Ethnicity
Are you Hispanic, Latino/a, or Spanish origin?
Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish
origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, Another Hispanic, Latino, or Spanish
origin
X. Patient unable to respond

Rationale for
Change / Comments
Updated version
number.
Updated footer.
A1000 is deleted and
replaced with A1005
and A1010.

A1000 is deleted and
replaced with
A1005. Proposed as
SPADE in the FY
2020 IPPS/LTCH PPS
proposed rule. Aligns
with 2011 HHS race
and ethnicity data
standards for
person-level data
collection, while
maintaining the
1997 OMB minimum
data standards for
race and ethnicity.

Page 1 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#
5.

6.

Item Set(s)
Affected
Admission

Item / Text
Affected
A1010

Admission,
Planned
Discharge

A1100
A1100A
A1100B
A1110
A1110A
A1110B

LTCH CARE Data Set V 4.00
N/A – new item

A1100. Language
A. Does the patient need or want an
interpreter to communicate with a doctor
or health care staff?
0. No Skip to A1200, Marital Status
1. Yes Specify in A1100B, Preferred
language
9. Unable to determine Skip to A1200,
Marital Status
B. Preferred language:

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
A1010. Race
What is your race?
Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I. Vietnamese
J. Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Patient unable to respond
A1110. Language
A. What is your preferred language?

B. Do you need or want an interpreter to
communicate with a doctor or health care
staff?

Rationale for
Change / Comments
A1000 is deleted and
replaced with
A1010. Proposed as
SPADE in the FY
2020 IPPS/LTCH PPS
proposed rule. Aligns
with 2011 HHS race
and ethnicity data
standards for
person-level data
collection, while
maintaining the
1997 OMB minimum
data standards for
race and ethnicity.

A1100 is replaced
with A1110.
Proposed as SPADE
in the FY 2020
IPPS/LTCH PPS
proposed rule.

0. No
1. Yes
9. Unable to determine

Page 2 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#
7.

Item Set(s)
Affected
Admission,
Planned
Discharge

Item / Text
Affected
A1250

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
A1250. Transportation
Has lack of transportation kept you from
medical appointments, meetings, work, or from
getting things needed for daily living?

Rationale for
Change / Comments
Proposed as SPADE
in the FY 2020
IPPS/LTCH PPS
proposed rule.
Consistent with
Check all that apply
Healthy People 2020
A. Yes, it has kept me from medical
priority to address
appointments or from getting my medications patient social
B. Yes, it has kept me from non-medical
determinants of
meetings, appointments, work, or from getting health.
things that I need
C. No
D. Patient unable to respond

Page 3 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#
8.

Item Set(s)
Affected
Admission

Item / Text
Affected
A1802
A1805

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
Rationale for
LTCH CARE Data Set V 4.00
highlighted in yellow)
Change / Comments
A1802. Admitted From
A1805. Admitted From
Revised for PAC
Immediately preceding this admission,
01. Home/Community (e.g., private home/apt., alignment.
where was the patient?
board/care, assisted living, group home,
01. Community residential setting (e.g.,
transitional living, other residential care
private home/apt., board/care, assisted
arrangements)
living, group home, adult foster care)
02. Nursing home (long-term care facility)
02. Long-term care facility
03. Skilled Nursing Facility (SNF, swing beds)
03. Skilled nursing facility (SNF)
04. Short-term General Hospital (acute
04. Hospital emergency department
hospital, IPPS)
05. Short-stay acute hospital (IPPS)
05. Long-Term Care Hospital (LTCH)
06. Long-term care hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free
07. Inpatient rehabilitation facility or unit
standing facility or unit)
(IRF)
07. Inpatient Psychiatric Facility (psychiatric
08. Psychiatric hospital or unit
hospital or unit)
09. Intellectually Disabled/Developmentally 08. Intermediate Care Facility (ID/DD facility)
Disabled (ID/DD) facility
09. Hospice (home/non-institutional)
10. Hospice
10. Hospice (institutional facility)
99. None of the above
11. Critical Access Hospital (CAH)
12. Home under care of organized home
health service organization
99. Not Listed

Page 4 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#
9.

Item Set(s)
Affected
Planned
Discharge,
Unplanned
Discharge

10. Unplanned
Discharge

Item / Text
Affected
A2110
A2105

A1990

LTCH CARE Data Set V 4.00
A2110. Discharge Location
01. Community residential setting (e.g.,
private home/apt., board/care, assisted
living, group home, adult foster care)
02. Long-term care facility
03. Skilled nursing facility (SNF)
04. Hospital emergency department
05. Short-stay acute hospital (IPPS)
06. Long-term care hospital (LTCH)
07. Inpatient rehabilitation facility or unit
(IRF)
08. Psychiatric hospital or unit
09. Intellectually Disabled/
Developmentally Disabled (ID/DD) facility
10. Hospice
12. Discharged Against Medical Advice
98. Other

N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
A2105. Discharge Location
01. Home/Community (e.g., private home/apt.,
board/care, assisted living, group home,
transitional living, other residential care
arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute
hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free
standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric
hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home
health service organization
99. Not Listed
A1990. Patient discharged against medical
advice?
0. No
1. Yes

Rationale for
Change / Comments
Revised for Transfer
of Health
Information measure
calculation and PAC
alignment.

Removed as a
response option
from A2105
(formerly A2110)
and created as its
own data element.

Page 5 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
11. Planned
Discharge,
Unplanned
Discharge

Item / Text
Affected
A2121

LTCH CARE Data Set V 4.00
N/A – new item

12. Planned
Discharge,
Unplanned
Discharge

A2122

N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
A2121. Provision of Current Reconciled
Medication List to Subsequent Provider at
Discharge
At the time of discharge to another provider,
did your facility provide the patient’s current
reconciled medication list to the subsequent
provider?
0. No – Current reconciled medication list not
provided to the subsequent provider
1. Yes – Current reconciled medication list
provided to the subsequent provider
A2122. Provision of Current Reconciled
Medication List to Patient at Discharge
At the time of discharge, did your facility
provide the patient’s current reconciled
medication list to the patient, family and/or
caregiver?
0. No – Current reconciled medication list not
provided to the patient, family and/or caregiver
1. Yes – Current reconciled medication list
provided to the patient, family and/or caregiver

Rationale for
Change / Comments
New data element
added for the
Transfer of Health
Information quality
measures.

New data element
added for the
Transfer of Health
Information quality
measures.

Page 6 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
13. Planned
Discharge,
Unplanned
Discharge

14. Admission

Item / Text
Affected
A2123A1
A2123A2
A2123B1
A2123B2
A2123C1
A2123C2
A2123D1
A2123D2
A2123E1
A2123E2

B0200

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
A2123. Route of Current Reconciled
Medication List Transmission
Indicate the route(s) of transmission of the
current reconciled medication list to the
subsequent provider and/or
patient/family/caregiver.

Rationale for
Change / Comments
New data element
added for the
Transfer of Health
Information quality
measures.

1. To subsequent provider
2. To patient/family/caregiver

N/A – new item

Check all that apply
A. Electronic Health Record
B. Health Information Exchange
Organization
C. Verbal (e.g., in-person, telephone,
video conferencing)
D. Paper-based (e.g., fax, copies,
printouts)
E. Other Methods (e.g., texting, email, CDs)
B0200. Hearing
Ability to hear (with hearing aid or hearing
appliances if normally used)
0. Adequate - no difficulty in normal
conversation, social interaction, listening to TV.
1. Minimal difficulty - difficulty in some
environments (e.g., when person speaks softly
or setting is noisy).
2. Moderate difficulty - speaker has to increase
volume and speak distinctly.
3. Highly impaired - absence of useful hearing

Added to assess
Hearing in Section B
– Speech, Hearing,
and Vision. MDS
currently assesses
this but it is missing
from previous
versions of the LTCH
CARE Data Set.
National Beta Test
data supports crosssetting reliability and
feasibility.
Page 7 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
15. Admission

Item / Text
Affected
B1000

LTCH CARE Data Set V 4.00
N/A – new item

16. Admission,
Planned
Discharge

B1300

N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
B1000. Vision
Ability to see in adequate light (with glasses or
other visual appliances)
0. Adequate - sees fine detail, such as regular
print in newspapers/books
1. Impaired - sees large print, but not regular
print in newspapers/books
2. Moderately impaired - limited vision; not
able to see newspaper headlines but can
identify objects
3. Highly impaired - object identification in
question, but eyes appear to follow objects
4. Severely impaired - no vision or sees only
light, colors or shapes; eyes do not appear to
follow objects.
B1300. Health Literacy
How often do you need to have someone help
you when you read instructions, pamphlets, or
other written material from your doctor or
pharmacy?
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

Rationale for
Change / Comments
Added to assess
Vision in Section B –
Speech, Hearing, and
Vision. MDS
currently assesses
this but it is missing
from previous
versions of the LTCH
CARE Data Set.
National Beta Test
data supports crosssetting reliability and
feasibility.
Proposed as SPADE
in the FY 2020
IPPS/LTCH PPS
proposed rule.
Recommended for
inclusion in
Medicare data by
HHS and the
National Academies
of Sciences,
Engineering and
Medicine (NASEM).

Page 8 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
17. Admission,
Planned
Discharge

Item / Text
Affected
C0100

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
C0100. Should Brief Interview for Mental
Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
0. No (patient is rarely/never understood)
Skip to XXXX
1. Yes Continue to C0200. Repetition of
Three Words

Rationale for
Change / Comments
Added BIMS to
Cognitive Patterns
section of the LTCH
CARE Data Set to
assess mental status.
Most public
comments
supportive of
including BIMS. TEP
supported use of
BIMS. Testing
supports use of MDS
version of BIMS.
National Beta Test
data supports crosssetting reliability and
feasibility.

Page 9 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
18. Admission,
Planned
Discharge

Item / Text
Affected
C0200

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
C0200. Repetition of Three Words.

Rationale for
Change / Comments
Added BIMS to
Cognitive Patterns
Ask patient: “I am going to say three words for section of the LTCH
you to remember. Please repeat the words after CARE Data Set to
I have said all three. The words are: sock, blue, assess mental status.
and bed. Now tell me the three words.”
Most public
comments
Number of words repeated by patient after
supportive of
first attempt
including BIMS. TEP
0. None.
supported use of
1. One.
BIMS. Testing
2. Two.
supports use of MDS
3. Three.
version of BIMS.
National Beta Test
data supports crossAfter the patient's first attempt, repeat the
setting reliability and
words using cues ("sock, something to wear;
feasibility.
blue, a color; bed, a piece of furniture"). You
may repeat the words up to two more times.

Page 10 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
19. Admission,
Planned
Discharge

Item / Text
Affected
C0300
C0300A
C0300B
C0300C

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
C0300. Temporal Orientation (orientation to
year, month, and day).

Rationale for
Change / Comments
Added BIMS to
Cognitive Patterns
section of the LTCH
Ask patient: "Please tell me what year it is right CARE Data Set to
now."
assess mental status.
A. Able to report correct year
Most public
0. Missed by > 5 years or no answer
comments
1. Missed by 2-5 years
supportive of
2. Missed by 1 year
including BIMS. TEP
3. Correct.
supported use of
BIMS. Testing
Ask patient: "What month are we in right
supports use of MDS
now?"
version of BIMS.
B. Able to report correct month.
National Beta Test
0. Missed by > 1 month or no answer
data supports cross1. Missed by 6 days to 1 month
setting reliability and
2. Accurate within 5 days
feasibility.
Ask patient: "What day of the week is today?"
C. Able to report correct day of the week.
0. Incorrect or no answer
1. Correct

Page 11 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
20. Admission,
Planned
Discharge

Item / Text
Affected
C0400
C0400A
C0400B
C0400C

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
C0400. Recall

Rationale for
Change / Comments
Added BIMS to
Cognitive Patterns
section of the LTCH
Ask patient: "Let's go back to an earlier
question. What were those three words that I
CARE Data Set to
asked you to repeat?" If unable to remember a assess mental status.
word, give cue (something to wear; a color; a
Most public
piece of furniture) for that word.
comments
supportive of
A. Able to recall "sock”
including BIMS. TEP
0. No - could not recall
supported use of
1. Yes, after cueing ("something to wear")
BIMS. Testing
2. Yes, no cue required
supports use of MDS
version of BIMS.
National Beta Test
B. Able to recall "blue"
0. No - could not recall
data supports cross1. Yes, after cueing ("a color")
setting reliability and
2. Yes, no cue required
feasibility.
C. Able to recall "bed"
0. No - could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

Page 12 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
21. Admission,
Planned
Discharge

Item / Text
Affected
C0500

22. Admission

C1610A
C1610B
C1610C
C1610D
C1610E
C1610E1
C1610E2
C1310A
C1310B
C1310C
C1310D

LTCH CARE Data Set V 4.00
N/A – new item

C1610. Signs and Symptoms of Delirium
(from CAM©)
Confusion Assessment Method (CAM©)
Shortened Version Worksheet (3-day
assessment period)
Acute Onset and Fluctuating Course
A. Is there evidence of an acute change in
mental status from the patient's baseline?
B. Did the (abnormal) behavior fluctuate
during the day, that is, tend to come and go
or increase and decrease in severity?

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
C0500. BIMS Summary Score

Rationale for
Change / Comments
Added BIMS to
Cognitive Patterns
Add scores for questions C0200-C0400 and fill section of the LTCH
in total score (00-15)
CARE Data Set to
Enter 99 if the patient was unable to complete assess mental status.
the interview
Most public
comments
supportive of
including BIMS. TEP
supported use of
BIMS. Testing
supports use of MDS
version of BIMS.
National Beta Test
data supports crosssetting reliability and
feasibility.
C1310. Signs and Symptoms of Delirium (from C1610 will be
CAM©)
replaced by C1310 in
order to standardize
Code after completing Brief Interview for
across PAC settings.
Mental Status and reviewing medical record.
TEP supportive of
CAM use across
A. Acute Onset Mental Status Change
Is there evidence of an acute change in mental settings. National
Beta Test data
status from the patient's baseline?
supports cross0. No
setting reliability and
1. Yes
feasibility of CAM.

Page 13 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

Item / Text
Affected

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
Rationale for
LTCH CARE Data Set V 4.00
highlighted in yellow)
Change / Comments
Inattention
Enter Codes in Boxes
C. Did the patient have difficulty focusing
B. Inattention - Did the patient have difficulty
attention, for example, being easily
focusing attention, for example being easily
distractible or having difficulty keeping track distractible or having difficulty keeping track of
of what was being said?
what was being said?
Disorganized Thinking
C. Disorganized thinking - Was the patient's
D. Was the patient's thinking disorganized or thinking disorganized or incoherent (rambling
incoherent, such as rambling or irrelevant
or irrelevant conversation, unclear or illogical
conversation, unclear or illogical flow of
flow of ideas, or unpredictable switching from
ideas, or unpredictable switching from
subject to subject)?
subject to subject?
D. Altered level of consciousness - Did the
Altered Level of Consciousness
patient have altered level of consciousness as
E. Overall, how would you rate the patient's indicated by any of the following criteria?
level of consciousness?
• vigilant – startled easily to any sound
E1. Alert (Normal)
or touch
E2. Vigilant (hyperalert) or Lethargic
• lethargic – repeatedly dozed off when
(drowsy, easily aroused) or Stupor (difficult
being asked questions, but responded
to arouse) or Coma (unarousable)
to voice or touch
• stuporous – very difficult to arouse and
keep aroused for the interview
• comatose – could not be aroused
Coding:
0. Behavior not present
1. Behavior continuously present, does not
fluctuate
2. Behavior present, fluctuates (comes and
goes, changes in severity)

Page 14 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
23. Planned
Discharge,
Unplanned
Discharge

Item / Text
Affected
C1610A
C1610B
C1610C
C1610D
C1610E
C1610E1
C1610E2
C1310A
C1310B
C1310C
C1310D

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
C1310. Signs and Symptoms of Delirium (from
CAM©)
Code after completing Brief Interview for
Mental Status and reviewing medical record.

Rationale for
Change / Comments
C1610 will be
replaced by C1310 in
order to standardize
across PAC settings.
TEP supportive of
CAM use across
A. Acute Onset Mental Status Change
Acute Onset and Fluctuating Course
Is there evidence of an acute change in mental settings. National
Beta Test data
A. Is there evidence of an acute change in
status from the patient's baseline?
supports crossmental status from the patient's baseline?
0. No
setting reliability and
B. Did the (abnormal) behavior fluctuate
1. Yes
feasibility of CAM.
during the day, that is, tend to come and go
or increase and decrease in severity?
Enter Codes in Boxes
Inattention
B. Inattention - Did the patient have difficulty Coding instructions
C. Did the patient have difficulty focusing
for Unplanned
focusing attention, for example being easily
attention, for example, being easily
distractible or having difficulty keeping track of Discharge will be:
distractible or having difficulty keeping track what was being said?
Code after reviewing
of what was being said?
medical record.
C. Disorganized thinking - Was the patient's
Disorganized Thinking
thinking disorganized or incoherent (rambling
D. Was the patient's thinking disorganized or or irrelevant conversation, unclear or illogical
incoherent, such as rambling or irrelevant
flow of ideas, or unpredictable switching from
conversation, unclear or illogical flow of
subject to subject).
ideas, or unpredictable switching from
D. Altered level of consciousness - Did the
subject to subject?
patient have altered level of consciousness as
Altered Level of Consciousness
indicated by any of the following criteria?
E. Overall, how would you rate the patient's
• vigilant – startled easily to any sound
level of consciousness?
or touch
E1. Alert (Normal)
• lethargic – repeatedly dozed off when
E2. Vigilant (hyperalert) or Lethargic
being asked questions, but responded
(drowsy, easily aroused) or Stupor (difficult
to voice or touch
to arouse) or Coma (unarousable)
• stuporous – very difficult to arouse and
keep aroused for the interview
• comatose – could not be aroused
LTCH CARE Data Set V 4.00
C1610. Signs and Symptoms of Delirium
(from CAM©)
Confusion Assessment Method (CAM©)
Shortened Version Worksheet (3-day
assessment period)

Page 15 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

Item / Text
Affected

24. Admission,
Planned
Discharge,
Unplanned
Discharge

CAM © Footnote

25. Admission,
Planned
Discharge

D0150
D0150A1
D0150A2
D0150B1
D0150B2
D0150C1
D0150C2
D0150D1
D0150D2
D0150E1
D0150E2
D0150F1
D0150F2
D0150G1
D0150G2

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
Coding:
0. Behavior not present
1. Behavior continuously present, does not
fluctuate
2. Behavior present, fluctuates (comes and
goes, changes in severity)
Confusion Assessment Method. ©1988, 2003,
Hospital Elder Life Program. All rights reserved.
Adopted from: Inouye SK et al. Ann Intern Med.
1990; 113:941-8. Used with permission.

Adapted with permission from: Inouye SK
et al., Clarifying confusion: The Confusion
Assessment Method. A new method for
detection of delirium. Annals of Internal
Medicine. 1990; 113: 941-948. Confusion
Assessment Method: Training Manual and
Coding Guide, Copyright 2003, Hospital Elder
Life Program, LLC. Not to be reproduced
without permission.
N/A – new item
D0150. Patient Mood Interview (PHQ-2 to 9)
Say to patient: "Over the last 2 weeks, have
you been bothered by any of the following
problems?"

Rationale for
Change / Comments

The footnote
associated with
C1610 will be
replaced by the
footnote associated
with C1310. TEP
supportive of CAM
use.

Adding PHQ-2 to 9 to
the LTCH CARE Data
Set. Stakeholder and
expert input,
including public
If symptom is present, enter 1 (yes) in column comments and the
1, Symptom Presence.
TEP, supportive of
using PHQ-2 as
If yes in column 1, then ask the patient: "About gateway to full PHQhow often have you been bothered by this?"
9 depression
screening. This
Read and show the patient a card with the
approach reduces
symptom frequency choices. Indicate response burden while
in column 2, Symptom Frequency.
ensuring that

Page 16 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

Item / Text
Affected
D0150H1
D0150H2
D0150I1
D0150I2

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
9. No response (leave column 2 blank)
2. Symptom Frequency
0. Never or 1 day
1. 2-6 days (several days)
2. 7-11 days (half or more of the days)
3. 12-14 days (nearly every day)
Enter scores in boxes.
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or
3, CONTINUE asking the questions below. If
not, END the PHQ interview and SKIP to
next section.
C. Trouble falling or staying asleep, or sleeping
too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are
a failure or have let yourself or your family
down
G. Trouble concentrating on things, such as
reading the newspaper or watching television
H. Moving or speaking so slowly that other
people could have noticed. Or the opposite –
being so fidgety or restless that you have been
moving around a lot more than usual
I. Thoughts that you would be better off dead,
or of hurting yourself in some way

Rationale for
Change / Comments
patients with some
depressive
symptoms are
screening with full
PHQ-9. Results of
the National Beta
Test support the
PHQ-2 to 9 as
feasible and reliable
across PAC settings.

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Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
26. Admission,
Planned
Discharge

Item / Text
Affected
D0160

27. Admission,
Planned
Discharge

D0700

28. Admission,
Planned
Discharge

GG0170F

29. Admission,
Planned
Discharge

GG0170I

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
D0160. Total Severity Score

Add scores for all frequency responses in
Column 2, Symptom Frequency.
Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e.,
Symptom Frequency is blank for 3 or more
required items).
N/A – new item
D0700. Social Isolation
How often do you feel lonely or isolated from
those around you?
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond
F. Toilet transfer: The ability to get on and
F. Toilet transfer: The ability to get on and off a
off a toilet or commode.
toilet or commode. If admission performance is
coded 07, 09, 10, or 88 Skip to GG0170I, Walk
10 feet
I. Walk 10 feet: Once standing, the ability to I. Walk 10 feet: Once standing, the ability to
walk at least 10 feet in a room, corridor, or walk at least 10 feet in a room, corridor, or
similar space. If admission performance is
similar space. If admission performance is
coded 07, 09, 10, or 88 Skip to GG0170Q1, coded 07, 09, 10, or 88 Skip to GG0170M, 1
step (curb)
Does the patient use a wheelchair and/or
scooter?

Rationale for
Change / Comments
Adding PHQ-2 to 9 to
the LTCH CARE Data
Set.

Proposed as SPADE
in the FY 2020
IPPS/LTCH PPS
proposed rule.
Recommended for
inclusion in
Medicare data by
HHS and the NASEM.
Added skip pattern.

Updated skip
pattern.

Page 18 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
30. Admission,
Planned
Discharge

Item / Text
Affected
GG0170G
GG0170L
GG0170M
GG0170N
GG0170O
GG0170P

LTCH CARE Data Set V 4.00
N/A – new items

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
Rationale for
highlighted in yellow)
Change / Comments
G. Car transfer: The ability to transfer in and
Proposed as SPADE
out of a car or van on the passenger side. Does in FY 2020 IPPS/LTCH
not include the ability to open/close door or
PPS proposed rule.
fasten seat belt.
L. Walking 10 feet on uneven surfaces: The
ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or
gravel.
M. 1 step (curb): The ability to go up and down
a curb and/or up and down one step. If
admission performance is coded 07, 09, 10, or
88 Skip to GG0170P, Picking up object
N. 4 steps: The ability to go up and down four
steps with or without a rail. If admission
performance is coded 07, 09, 10, or 88 Skip to
GG0170P, Picking up object
O. 12 steps: The ability to go up and down 12
steps with or without a rail.
P. Picking up object: The ability to bend/stoop
from a standing position to pick up a small
object, such as a spoon, from the floor.

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Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
31. Admission,
Planned
Discharge

32. Admission,
Planned
Discharge

Item / Text
Affected
J0510

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
J0510. Pain Effect on Sleep
Ask patient: “Over the past 5 days, how much
of the time has pain made it hard for you to
sleep at night?”

J0520

N/A – new item

0. Does not apply – I have not had any pain or
hurting in the past 5 days Skip to XXXX
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer
J0520. Pain Interference with Therapy
Activities
Ask patient: “Over the past 5 days, how often
have you limited your participation in
rehabilitation therapy sessions due to pain?”

Rationale for
Change / Comments
TEP comments and
National Beta Test
data supports crosssetting reliability and
feasibility.

TEP comments and
National Beta Test
data supports crosssetting reliability and
feasibility.

0. Does not apply – I have not received
rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

Page 20 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
33. Admission,
Planned
Discharge

34. Admission

Item / Text
Affected
J0530

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
J0530. Pain Interference with Day-to-Day
Activities
Ask patient: “Over the past 5 days, how often
have you limited your day-to-day activities
(excluding rehabilitation therapy sessions)
because of pain?”

K0520
K0520A
K0520B
K0520C
K0520D
K0520Z

N/A – new item

Rationale for
Change / Comments
TEP comments and
National Beta Test
data supports crosssetting reliability and
feasibility.

1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer
K0520. Nutritional Approaches
Check all of the following nutritional
approaches that apply on admission.

Included to align
with MDS’
assessment of
nutritional status.
Check all that apply
Total parenteral
A. Parenteral/IV feeding
nutrition appears in
B. Feeding tube (e.g., nasogastric or abdominal Section O of LTCH
(PEG))
CARE Data Set V
C. Mechanically altered diet – require change 4.00, but other
in texture of food or liquids (e.g., pureed food, nutritional
thickened liquids)
approaches are not
D. Therapeutic diet (e.g., low salt, diabetic, low assessed, so for
cholesterol)
completeness and
Z. None of the above
cross-setting
standardization,
item K0520 will
mirror the MDS.

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Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
35. Planned
Discharge,
Unplanned
Discharge

Item / Text
Affected
K0520
K0520A1
K0520A2
K0520B1
K0520B2
K0520C1
K0520C2
K0520D1
K0520D2
K0520Z1
K0520Z2

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
K0520. Nutritional Approaches

Rationale for
Change / Comments
Included to align
with MDS’
1. Last 7 days
assessment of
Check all of the nutritional approaches nutritional status.
that were received in the last 7 days
Total parenteral
2. At discharge
nutrition appears in
Check all of the nutritional approaches Section O of LTCH
that were being received at discharge CARE Data Set V
4.00, but other
Check all that apply
nutritional
A. Parenteral/IV feeding
approaches are not
B. Feeding tube (e.g., nasogastric or abdominal assessed, so for
(PEG))
completeness and
C. Mechanically altered diet – require change cross-setting
in texture of food or liquids (e.g., pureed food, standardization,
thickened liquids)
item K0520 will
D. Therapeutic diet (e.g., low salt, diabetic, low mirror the MDS.
cholesterol)
Z. None of the above

Page 22 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
36. Admission

Item / Text
Affected
N0415A1
N0415A2
N0415E1
N0415E2
N0415F1
N0415F2
N0415H1
N0415H2
N0415I1
N0415I2
N0415J1
N0415J2

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
N0415. High-Risk Drug Classes: Use and
Indication
1. Is taking
Check if the patient is taking any
medications in the following drug
classes
2. Indication noted
If Column 1 is checked, check if there is
an indication noted for all medications
in the drug class

Rationale for
Change / Comments
TEP comments and
National Beta Test
data supports crosssetting reliability and
feasibility.

Check all that apply
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

Page 23 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
37. Planned
Discharge,
Unplanned
Discharge

38. Admission

Item / Text
Affected
N0420A1
N0420A2
N0420E1
N0420E2
N0420F1
N0420F2
N0420H1
N0420H2
N0420I1
N0420I2
N0420J1
N0420J2

O0100
O0110

39. Planned
Discharge,
Unplanned
Discharge

O0110

LTCH CARE Data Set V 4.00
N/A – new item

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
N0420. High-Risk Drug Classes: Use and
Indication
1. Is taking
Check if the patient is taking any
medications in the following drug
classes
2. Indication noted
If Column 1 is checked, check if there is
an indication noted for all medications
in the drug class

O0100. Special Treatments, Procedures,
and Programs
Check all the treatments at admission. For
dialysis, check if it is part of the patient's
treatment plan.
Check all that apply
N/A – new item

Check all that apply
A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
O0110. Special Treatments, Procedures, and
Programs
Check all of the following treatments,
procedures, and programs that apply on
admission.
Check all that apply
O0110. Special Treatments, Procedures, and
Programs
Check all of the following treatments,
procedures, and programs that apply at
discharge.

Rationale for
Change / Comments
TEP comments and
National Beta Test
data supports crosssetting reliability and
feasibility.

TEP comments and
National Beta Test
data supports crosssetting reliability and
feasibility.
Included to align
with the MDS.

Check all that apply
Page 24 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
40. Admission,
Planned
Discharge,
Unplanned
Discharge;
note: “a” is
used for item
numbering for
admission
while “b” is
used for item
numbering for
discharge
41. Admission,
Planned
Discharge,
Unplanned
Discharge;
note: “a” is
used for item
numbering for
admission
while “b” is
used for item
numbering for
discharge

Item / Text
Affected
O0110A1a
O0110A2a
O0110A3a
O0110A10a
O0110B1a

LTCH CARE Data Set V 4.00
N/A – new items

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other

O0110A1b
O0110A2b
O0110A3b
O0110A10b
O0110B1b

B1. Radiation

O0100G

Respiratory Treatments

Respiratory Therapies

O0110C1a
O0110C2a
O0110C3a
O0110C4a
O0110D1a
O0110D2a
O0110D3a
O0110E1a
O0110G1a
O0110G2a
O0110G3a

G. Non-invasive Ventilator (BiPAP, CPAP)

C1. Oxygen Therapy

O0110C1b
O0110C2b
O0110C3b
O0110C4b
O0110D1b

C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As needed
E1. Tracheostomy Care
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP

Rationale for
Change / Comments
Included to align
with the MDS, and
public comment and
subject matter
experts support
breaking the parent
item
“chemotherapy” into
type of
chemotherapy to
distinguish patient
complexity/burden
of care.
Included to align
with the MDS, and
public comment and
subject matter
experts support:
breaking the parent
item “oxygen
therapy” into
continuous vs.
intermittent to
distinguish patient
complexity/burden
of care; breaking the
parent item
“suctioning” into
frequency of
suctioning to
distinguish patient
complexity/burden
Page 25 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

42. Planned
Discharge,
Unplanned
Discharge;
note: “b” is
used for item
numbering for
discharge
43. Admission,
Planned
Discharge,
Unplanned
Discharge;
note: “a” is
used for item
numbering for
admission
while “b” is
used for item
numbering for
discharge

Item / Text
Affected
O0110D2b
O0110D3b
O0110E1b
O0110G1b
O0110G2b
O0110G3b
O0110F1b

O0100H
O0100H2a
O0100J
O0100N
O0100Z
O0110H1a
O0110H2a
O0110H3a
O0110H4a
O0110H10a
O0110I1a
O0110J1a
O0110J2a

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)

N/A – new item

F1. Invasive Mechanical Ventilator (ventilator
or respirator)

Other Treatments

Other

H. IV Medications (if checked, please
specify below)
H2a. Vasoactive medications (i.e.,
continuous infusions of
vasopressors or inotropes)

H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other

J. Dialysis
N. Total Parenteral Nutrition

I1. Transfusions

None of the Above
Z. None of the above

J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis

Rationale for
Change / Comments
of care. In public
comment, there was
support for breaking
the parent item into
2 response options
(BiPAP and CPAP).
Data elements that
capture invasive
mechanical
ventilation are
currently in use in
the MDS 3.0 and
LTCH CARE Data Set.
In public comment,
there was support
for: further
delineating types of
IV medications (and
the new vasoactive
medication item,
O0110H2, is included
in the ventilator
liberation quality
measures); breaking
out the dialysis
parent item into
type of dialysis;

Page 26 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

44. Admission

Item / Text
Affected
O0110J3a
O0110O1a
O0110O2a
O0110O3a
O0110O4a
O0110Z1a
O0110H1b
O0110H2b
O0110H3b
O0110H4b
O0110H10b
O0110I1b
O0110J1b
O0110J2b
O0110J3b
O0110O1b
O0110O2b
O0110O3b
O0110O4b
O0110Z1b
O0150
O0150A
O0150A2
O0150B

LTCH CARE Data Set V 4.00

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
O1. IV Access

Rationale for
Change / Comments
breaking out the IV
access parent item
O2. Peripheral
(which appears on
O3. Midline
the MDS) into types
O4. Central (e.g., PICC, tunneled, port) of IV access.

None of the Above
Z1. None of the above

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

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

Language deleted
from O0150B. Skip
patterns updated.
Additional edits

Page 27 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

Item / Text
Affected
O0150C
O0150D
O0150E

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
LTCH CARE Data Set V 4.00
highlighted in yellow)
A. Invasive Mechanical Ventilation Support (Note: Day 2 = Date of Admission to the LTCH
upon Admission to the LTCH
(Day 1) + 1 calendar day)
0. No, not on invasive mechanical
ventilation support Skip to O0250,
A. Invasive Mechanical Ventilation Support
Influenza Vaccine
upon Admission to the LTCH
1. Yes, weaning Continue to O0150B,
0. No, not on invasive mechanical ventilation
Assessed for readiness for SBT by day 2 of
support upon admission Skip to Z0400,
the LTCH stay
Signature of Persons Completing the
2. Yes, non-weaning Skip to O0250,
Assessment
Influenza Vaccine
1. Yes, on invasive mechanical ventilation
support upon admission Continue to
B. Assessed for readiness for SBT by day 2
O0150A2, Ventilator Weaning Status
of the LTCH stay (Note: Day 2 = Date of
Admission to the LTCH (Day 1) + 1 calendar
A2. Ventilator Weaning Status
day)
0. No, determined to be non-weaning
upon admission Skip to Z0400,
0. No Skip to O0250, Influenza Vaccine
Signature of Persons Completing the
1. Yes Continue to O0150C, Deemed
Assessment
medically ready for SBT by day 2 of the LTCH
1.Yes, determined to be weaning upon
stay
admission Continue to O0150B,
Assessed for readiness for SBT by day 2
C. Deemed medically ready for SBT by day 2
of LTCH stay
of the LTCH stay
0. No Continue to O0150D, Is there
B. Assessed for readiness for SBT by day 2 of
documentation of reason(s) in the patient’s the LTCH stay
medical record that the patient was deemed 0. No Skip to Z0400, Signature of Persons
medically unready for SBT by day 2 of the
Completing the Assessment
LTCH stay?
1. Yes Continue to O0150C, Deemed
1. Yes Continue to O0150E, SBT performed medically ready for SBT by day 2 of the LTCH
by day 2 of the LTCH stay
stay

Rationale for
Change / Comments
made for
clarification.
Addition of O0150A2
for resolve conflict
regarding the
SNOMED codes.

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Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)

#

Item Set(s)
Affected

Item / Text
Affected

LTCH CARE Data Set V 4.00
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

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
Rationale for
highlighted in yellow)
Change / Comments
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, If the patient was
deemed medically ready for SBT, was 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 Z0400, Signature of Persons
Completing the Assessment
1. Yes Skip to Z0400, Signature of Persons
Completing the Assessment
E. If the patient was deemed medically ready
for SBT, was SBT performed by day 2 of the
LTCH stay?
0. No
1. Yes

Page 29 of 30

Change Table for Proposed LTCH QRP New and Modified Items – Effective Date: October 1, 2020 (continued)
Item Set(s)
#
Affected
45. Planned
Discharge,
Unplanned
Discharge

Item / Text
Affected
O0200
O0200A

LTCH CARE Data Set V 5.00
(Note: Modifications to existing items
highlighted in yellow)
O0200. Ventilator Liberation Rate (Note: 2
calendar days prior to discharge = 2 calendar
days + day of discharge)

Rationale for
Change / Comments
Added clarification
on the definition of 2
A. Invasive Mechanical Ventilator:
calendar days prior
Liberation Status at Discharge
to discharge.
0. Not fully liberated at discharge (i.e.,
A. Invasive Mechanical Ventilator: Liberation Additionally, clarified
patient required partial or full invasive
Status at Discharge
wording for code 9
mechanical ventilation support within 2
0. Not fully liberated at discharge (i.e., patient that the item is
calendar days prior to discharge)
required partial or full invasive mechanical
referencing the
1. Fully liberated at discharge (i.e., patient ventilation support within 2 calendar days prior invasive mechanical
did not require any invasive mechanical
to discharge)
ventilator support
ventilation support for at least 2 consecutive 1. Fully liberated at discharge (i.e., patient did on admission as
calendar days immediately prior to
not require any invasive mechanical ventilation opposed to the new
discharge)
support for at least 2 consecutive calendar days similar item on
9. NA (code only if the patient was nonimmediately prior to discharge)
discharge.
weaning or not ventilated on admission
9. Not applicable (code only if the patient was
[O0150A=2 or 0 on Admission Assessment]) not on invasive mechanical ventilator support
upon admission [O0150A = 0] or the patient
was determined to be non-weaning upon
admission [O0150A2 = 0])
LTCH CARE Data Set V 4.00
O0200. Ventilator Liberation Rate

Page 30 of 30