Long Term Care Data Set

Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1163 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10409 Long Term Care Data Set Form and Instruction
CMS-10409 LCDS version 5.1 Admission LTCH-CARE-Data-Set-Version-5.1-Admission_v2.docx Form and Instruction
CMS-10409 LCDS version 5.1 Admission LTCH-CARE-Data-Set-Version-5.1-Admission_v2.docx Form and Instruction
CMS-10409 LCDS version 5.1 Expired LTCH-CARE-Data-Set-Version-5.1-Expired_v3.docx Form and Instruction
CMS-10409 LCDS version 5.1 Expired LTCH-CARE-Data-Set-Version-5.1-Expired_v3.docx Form and Instruction
CMS-10409 LCDS version 5.1 Planned Discharge LTCH-CARE-Data-Set-Version-5.1-Planned-Discharge_v2.docx Form and Instruction
CMS-10409 LCDS version 5.1 Planned Discharge LTCH-CARE-Data-Set-Version-5.1-Planned-Discharge_v2.docx Form and Instruction
CMS-10409 LCDS version 5.1 Unplanned Discharge LTCH-CARE-Data-Set-Version-5.1-Unplanned-Discharge_v2.docx Form and Instruction
CMS-10409 LCDS version 5.1 Unplanned Discharge LTCH-CARE-Data-Set-Version-5.1-Unplanned-Discharge_v2.docx Form and Instruction
Crosswalk-LCDS-5.0-to-5.1.doc.docx Crosswalk IC Document
Crosswalk-LCDS-5.0-to-5.1.doc.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Long Term Care Data Set	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10409	LCDS version 5.1 Admission	LTCH-CARE-Data-Set-Version-5.1-Admission_v2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.1 Expired	LTCH-CARE-Data-Set-Version-5.1-Expired_v3.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.1 Planned Discharge	LTCH-CARE-Data-Set-Version-5.1-Planned-Discharge_v2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10409	LCDS version 5.1 Unplanned Discharge	LTCH-CARE-Data-Set-Version-5.1-Unplanned-Discharge_v2.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 415	Number of Respondents for Small Entity: 89

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	204,936	204,936
Annual IC Time Burden (Hours)	145,831	145,831
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk-LCDS-5.0-to-5.1.doc.docx	05/10/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.