CMS-10409 LCDS version 5.00 Unplanned 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 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 - UNPLANNED 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

Day

Year

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

Final LTCH CARE Data Set Version 5.00, Unplanned Discharge - 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, Unplanned Discharge - 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

A1990. Patient Discharged Against Medical Advice?
Enter Code

0. No
1. Yes

A2105. Discharge Location
Enter Code

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 bed)
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

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

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Patient

Identifier

Section A

Date

Administrative Information

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?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
Medication List to Patient at Discharge
1. Yes – Current reconciled medication list provided to the subsequent provider

Skip to A2123, Provision of Current Reconciled

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Check all that apply

Route of Transmission
A. Electronic Health Record
B. Health Information Exchange
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)

A2123. 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?
Enter Code

0. No – Current reconciled medication list not provided to the patient, family and/or caregiver
Delirium (from CAM©)
1. Yes – Current reconciled medication list provided to the patient, family and/or caregiver

Skip to C1310, Signs and Symptoms of

A2124. Route of Current Reconciled Medication List Transmission to Patient
Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.
Route of Transmission

Check all that apply

A. Electronic Health Record (e.g., electronic access to patient portal)
B. Health Information Exchange
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)

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

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Patient

Identifier

Section C

Date

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after reviewing medical record.

A. Acute Onset Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient’s baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously
present, does not fluctuate
2. Behavior present,
fluctuates (comes and goes,
changes in severity)

Enter Code in Boxes.
B. Inattention - Did the patient have difficulty focusing attention, for example being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized thinking - Was the patient’s thinking disorganized or incoherent (rambling or
irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to
subject)?
D. Altered level of consciousness - Did the patient have altered level of consciousness as indicated by
any of the following criteria?
• vigilant - startled easily to any sound or touch
• lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch
• stuporous - very difficult to arouse and keep aroused for the interview
• comatose - could not be aroused

Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to
be reproduced without permission.

Final LTCH CARE Data Set Version 5.00, Unplanned Discharge - 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 K0520, Nutritional Approaches
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, Unplanned Discharge - Effective October 1, 2022

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Patient

Section K

Identifier

Date

Swallowing/Nutritional Status

K0520. Nutritional Approaches
4. Last 7 Days
Check all of the nutritional approaches that were received in the last 7 days
5. At Discharge
Check all of the nutritional approaches that were being received at discharge

4.
Last 7 Days

5.
At Discharge

Check all that apply

Check all that apply

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

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

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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?
Skip to N0415, High-Risk Drug Classes: Use and Indication
0. No
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

Enter Number

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

Enter Number

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

Enter Number

Skip to M0300C, Stage 3.

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
Unstageable - Slough and/or eschar.

Skip to M0300F,

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

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

Enter Number

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

Enter Number

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

Enter Number

Skip to M0300G,

Skip to N0415, High-Risk Drug Classes:

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

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

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Patient

Identifier

Section N

Date

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications by pharmacological classification, not how it is used,
in the following classes
2. Indication noted
If column 1 is checked, check if there is an indication noted for all medications in the drug class

1.
Is taking

2.
Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above

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, Unplanned Discharge - Effective October 1, 2022

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
c.
At Discharge
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

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

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0200. Ventilator Liberation Rate (Note: 2 calendar days prior to discharge = 2 calendar days + day of discharge)
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. Not applicable (code only if the patient was not on invasive mechanical ventilator support upon admission [O0150A = 0] or the
patient was determined to be non-weaning upon admission [O0150A2 = 0])

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

Day

Year

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