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Long Term Care Data Set
Long Term Care Hospital (LTCH) Quality Reporting Program (CMS-10409)
OMB: 0938-1163
IC ID: 201171
OMB.report
HHS/CMS
OMB 0938-1163
ICR 202505-0938-009
IC 201171
( )
Documents and Forms
Document Name
Document Type
Form CMS-10409
Long Term Care Data Set
Form and Instruction
CMS-10409 LCDS version 5.3 Admission
LTCH-CARE-Data-Set-Version-5.3-Admission.pdf
Form and Instruction
CMS-10409 LCDS version 5.3 Expired
LTCH-CARE-Data-Set-Version-5.3-Expired.pdf
Form and Instruction
CMS-10409 LCDS version 5.3 Planned Discharge
LTCH-CARE-Data-Set-Version-5.3-Planned-DC.pdf
Form and Instruction
CMS-10409 LCDS version 5.3 Unplanned Discharge
LTCH-CARE-Data-Set-Version-5.3-Unplanned-DC.pdf
Form and Instruction
Crosswalk-LCDS-5.2-to-5.3.docx
Crosswalk
IC Document
Information Collection (IC) Details
View Information Collection (IC)
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
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10409
LCDS version 5.3 Admission
LTCH-CARE-Data-Set-Version-5.3-Admission.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10409
LCDS version 5.3 Expired
LTCH-CARE-Data-Set-Version-5.3-Expired.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10409
LCDS version 5.3 Planned Discharge
LTCH-CARE-Data-Set-Version-5.3-Planned-DC.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10409
LCDS version 5.3 Unplanned Discharge
LTCH-CARE-Data-Set-Version-5.3-Unplanned-DC.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
330
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
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
136,650
0
-90,290
0
0
226,940
Annual IC Time Burden (Hours)
185,101
0
-2,634
0
0
187,735
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Crosswalk
Crosswalk-LCDS-5.2-to-5.3.docx
05/27/2025
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.