CMS-10409 LCDS version 4.00 Planned Discharge

Patient

Identifier

Date

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1163 (Expiration Date: XX/XX/XXXX). The time required to complete this information collection is estimated
to average 21 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please
do not send applications, claims, payments, medical records, or any documents containing sensitive information to
the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please
contact Lorraine Wickiser at [email protected].

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Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 4.00
PATIENT ASSESSMENT FORM - PLANNED DISCHARGE

Section A

Administrative Information

A0050. Type of Record.
Enter Code

1. Add new assessment/record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers. Enter Code in boxes provided..
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Medicaid Provider Number:

A0200. Type of Provider.
Enter Code

3. Long-Term Care Hospital

A0210. Assessment Reference Date.
Observation end date:

_

_
Month

Year

Day

A0220. Admission Date
_

_
Month

Day

Year

A0250. Reason for Assessment .
Enter Code

01.
10.
11.
12.

Admission
Planned discharge
Unplanned discharge .
Expired

A0270. Discharge Date.
_

_
Month

Day

Year

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Patient

Identifier

Section A

Date

Administrative Information

Patient Demographic Information .
A0500. Legal Name of Patient.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number (or comparable railroad insurance number):

Final LTCH CARE Data Set Version 4.00, Planned Discharge - Effective July 1, 2018

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Patient

Identifier

Section A

Date

Administrative Information

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_

_
Month

Day

Year

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

A1400. Payer Information.
Check all that apply.
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care).
E. Workers' compensation
F. Title programs (e.g., Title III, V, or XX).
G. Other government (e.g., TRICARE, VA, etc.)
H. Private insurance/Medigap.
I. Private managed care
J. Self-pay.
K. No payer source
X. Unknown
Y. Other .

Final LTCH CARE Data Set Version 4.00, Planned Discharge - Effective July 1, 2018

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Patient

Identifier

Section A

Date

Administrative Information

A2110. Discharge Location
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
12.
98.

Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)
Long-term care facility
Skilled nursing facility (SNF)
Hospital emergency department
Short-stay acute hospital (IPPS)
Long-term care hospital (LTCH)
Inpatient rehabilitation facility or unit (IRF)
Psychiatric hospital or unit
Intellectually Disabled/Developmentally Disabled (ID/DD) facility
Hospice
Discharged Against Medical Advice
Other

Final LTCH CARE Data Set Version 4.00, Planned Discharge - Effective July 1, 2018

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Patient

Identifier

Section B

Date

Hearing, Speech, and Vision

B0100. Comatose
Enter Code

Persistent vegetative state/no discernible consciousness
0. No
Continue to BB0700, Expression of Ideas and Wants
1. Yes
Skip to GG0130, Self-Care

BB0700. Expression of Ideas and Wants (3-day assessment period)
Enter Code

Expression of ideas and wants (consider both verbal and non-verbal expression and excluding language barriers)
4. Expresses complex messages without difficulty and with speech that is clear and easy to understand
3. Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
2. Frequently exhibits difficulty with expressing needs and ideas
1. Rarely/Never expresses self or speech is very difficult to understand.

BB0800. Understanding Verbal and Non-Verbal Content (3-day assessment period)
Enter Code

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

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Patient

Section C

Identifier

Date

Cognitive Patterns

C1610. Signs and Symptoms of Delirium (from CAM©)
Confusion Assessment Method (CAM©) Shortened Version Worksheet (3-day assessment period)
CODING:
0. No
1. Yes

Enter Code in Boxes.
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?
Inattention
C. Did the patient have difficulty focusing attention, for example, being easily distractible or having
difficulty keeping track of what was being said?
Disorganized Thinking
D. 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?
Altered Level of Consciousness
E. Overall, how would you rate the patient's level of consciousness?
E1. Alert (Normal)
E2. Vigilant (hyperalert) or Lethargic (drowsy, easily aroused) or Stupor (difficult to arouse) or Coma
(unarousable)

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.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at
discharge, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
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.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
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

3.
Discharge
Performance.
Enter Codes in Boxes
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.
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.
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.

D. Wash upper body: The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at
discharge, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
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.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
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

3.
Discharge
Performance
Enter Codes in Boxes
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.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
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.
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.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
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?

J. Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period) - Continued
Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at
discharge, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
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.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
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

3.
Discharge
Performance
Enter Codes in Boxes
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
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
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Patient

Identifier

Section H

Date

Bladder and Bowel

H0350. Bladder Continence (3-day assessment period)
Enter Code

Bladder continence - Select the one category that best describes the patient..
0. Always continent (no documented incontinence)
1. Stress incontinence only
2. Incontinent less than daily (e.g., once or twice during the 3-day assessment period)
3. Incontinent daily (at least once a day)
4. Always incontinent
5. No urine output (e.g., renal failure)
9. Not applicable (e.g., indwelling catheter)

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Patient

Identifier

Section J

Date

Health Conditions

J1800. Any Falls Since Admission .
Enter Code

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 .

J1900. Number of Falls Since Admission .
Coding:
0. None
1. One
2. Two or more

Enter Codes in Boxes.
A. No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician;
no complaints of pain or injury by the patient; no change in the patient's behavior is noted after the fall
B. Injury (except major): Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any
fall-related injury that causes the patient to complain of pain
C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural
hematoma

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Patient

Identifier

Section M

Date

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

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/Injuries at Each Stage.
Enter Number

A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may
not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
1. Number of Stage 1 pressure injuries

Enter Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.- If 0

Enter Number

Skip to M0300C, Stage 3.

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Enter Number

1. Number of Stage 3 pressure ulcers - If 0
Enter Number

Skip to M0300D, Stage 4.

2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.

Enter Number

1. Number of Stage 4 pressure ulcers - If 0
Enter Number

Skip to M0300E, Unstageable - Non-removable dressing/device.

2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.

Enter Number

Enter Number

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

Skip to M0300F, Unstageable -

2. Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at
the time of admission.
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar If 0
Unstageable - Deep tissue injury.

Skip to M0300G,

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

M0300 continued on next page.

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Patient

Identifier

Section M

Date

Skin Conditions

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

G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0
Intervention

Enter Number

Skip to N2005, Medication

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

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Patient

Identifier

Section N

Date

Medications

N2005. Medication Intervention
Enter Code

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

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0200. Ventilator Liberation Rate.
Enter Code

A. Invasive Mechanical Ventilator: Liberation Status at Discharge
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 non-weaning or not ventilated on admission [O0150A=2 or 0 on Admission Assessment])

O0250. Influenza Vaccine - Refer to current version of LTCH Quality Reporting Program Manual for current influenza season and

reporting period..
Enter Code

A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No... Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes
Continue to O0250B, Date influenza vaccine received.
B. Date influenza vaccine received

_

_
Month
Enter Code

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

Day

Year

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

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Patient

Section Z

Identifier

Date

Assessment Administration

Z0400. Signature of Persons Completing the Assessment
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or
coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for payment from federal funds. I further
understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on
the accuracy and truthfulness of this information, and that submitting false information may subject my organization to a 2% reduction in the
Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf.
Signature.

Title.

Date Section
Completed.

Sections.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Assessment Completion.
A. Signature:

B. LTCH CARE Data Set Completion Date:

_

_
Month

Final LTCH CARE Data Set Version 4.00, Planned Discharge - Effective July 1, 2018

Day

Year

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