CMS-10409 LCDS version 5.00 Expired

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 24 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 Christy
Hughes at [email protected].

Final LTCH CARE Data Set Version 5.00, Admission - Effective October 1, 2022

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Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 5.00
PATIENT ASSESSMENT FORM - EXPIRED
Administrative Information

Section A
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. This is the date of death..
_

_
Month

Day

Year

Final LTCH CARE Data Set Version 5.00, Expired - Effective October 1, 2022

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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):

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

Final LTCH CARE Data Set Version 5.00, Expired - Effective October 1, 2022

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Patient

Identifier

Section A

Date

Administrative Information

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 5.00, Expired - Effective October 1, 2022

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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 N2005, Medication Intervention
1. Yes
Continue to J1900, Number of Falls Since Admission.

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

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

Final LTCH CARE Data Set Version 5.00, Expired - Effective October 1, 2022

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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. Not applicable - There were no potential clinically significant medication issues identified since admission or patient is not
taking any medications

Final LTCH CARE Data Set Version 5.00, Expired - Effective October 1, 2022

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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 5.00, Expired - Effective October 1, 2022

Day

Year

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