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 1 hour and 26 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].

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

Page 1 of 7

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 5.2
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.
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. This is the date of death.
–

Month

–

Day

Year

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

Page 2 of 7

Patient

Identifier

Date

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

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

Page 3 of 7

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

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

Page 4 of 7

Patient

Identifier

Section J

Date

Health Conditions

J1800. Any Falls Since Admission
Enter Code

Has the patient had any falls since admission?
0. No
1. Yes

Skip to N2005, Medication Intervention
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

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

Page 5 of 7

Patient

Identifier

Date

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

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

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

Page 6 of 7

Patient

Identifier

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

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

DRAFT LTCH CARE Data Set Version 5.2, Expired - Effective October 1, 2026

_
Day

Year

Page 7 of 7