CMS-10409 LCDS version 5.1 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 Ariel Cress at [email protected] and Lorraine Wickiser at [email protected].

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT RECORD & EVALUATION (CARE) DATA SET - Version 5.1 PATIENT ASSESSMENT FORM - EXPIRED

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.

1. National Provider Identifier (NPI):

2. CMS Certification Number (CCN):

3. 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. Admission

10. Planned discharge

11. Unplanned discharge

12. Expired

A0270. Discharge Date. This is the date of death.

–

–

Month Day Year

Patient Demographic Information

A0500. Legal Name of Patient

1. First name:

2. Middle initial:

3. Last name:

4. Suffix:

A0600. Social Security and Medicare Numbers

1. Social Security Number:

–

–

2. 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

Section A		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

Section J		Health Conditions
J1800. Any Falls Since Admission
Enter Code	Has the patient had any falls since admission? No Skip to N2005, Medication Intervention Yes Continue to J1900, Number of Falls Since Admission.
J1900. Number of Falls Since Admission
Coding: None One 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

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

Section O		Special Treatments, Procedures, and Programs
O0350. Patient’s COVID-19 vaccination is up to date.
Enter Code	0. No, patient is not up to date 1. Yes, patient is up to date

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	Sections	Date Section Completed
	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 Day Year

^{Final LTCH CARE Data Set Version 5.1, Expired - Effective October 1, 2024} Page 1 of 7