Form CMS-10409 LTCH Care Data Set Admissions

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 3.00
PATIENT ASSESSMENT FORM - ADMISSION

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

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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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

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section A.

Date

Administrative Information.

A1100. Language.
Enter Code

A. Does the patient need or want an interpreter to communicate with a doctor or health care staff?
0. No... Skip to A1200. Marital Status.
1. Yes
Specify in A1100B. Preferred language.
9. Unable to determine... Skip to A1200. Marital Status.
B. Preferred language:

A1200. Marital Status.
Enter Code

1.
2.
3.
4.
5.

Never married.
Married.
Widowed.
Separated.
Divorced.

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 payor source
X. Unknown
Y. Other .

Pre-Admission Service Use .
A1802. Admitted From. Immediately preceding this admission, where was the patient?.
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
99.

Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)
Long-term care facility
Skilled nursing facility (SNF)
Hospital emergency department
Short-stay acute hospital (IPPS)
Long-term care hospital (LTCH)
Inpatient rehabilitation facility or unit (IRF)
Psychiatric hospital or unit
ID/DD Facility
Hospice
None of the above

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section B.

Date

Hearing, Speech, and Vision.

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness .
0. No
Continue to BB0700. Expression of Ideas and Wants
Skip to GG0100. Prior Functioning: Everyday Activities
1. Yes

BB0700. Expression of Ideas and Wants (3-day assessment period)
Enter Code

Expression of ideas and wants (consider both verbal and non-verbal expression and excluding language barriers)
4. Expresses complex messages without difficulty and with speech that is clear and easy to understand
3. Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
2. Frequently exhibits difficulty with expressing needs and ideas
1. Rarely/Never expresses self or speech is very difficult to understand.

BB0800. Understanding Verbal Content (3-day assessment period)
Enter Code

Understanding Verbal Content (with hearing aid or device, if used and excluding language barriers)
4. Understands: Clear comprehension without cues or repetitions
3. Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand
2. Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand
1. Rarely/Never Understands

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Section C.

Identifier

Date

Cognitive Patterns.

C1610. Signs and Symptoms of Delirium (from CAM©)
Confusion Assessment Method (CAM©) Shortened Version Worksheet (3-day assessment period)
CODING:
0. No
1. Yes

Enter Code in Boxes.
Acute Onset and Fluctuating Course
A. Is there evidence of an acute change in mental status from the patient's baseline?
B. Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go or increase and
decrease in severity?
Inattention
C. Did the patient have difficulty focusing attention, for example, being easily distractible or having
difficulty keeping track of what was being said?
Disorganized Thinking
D. Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation,
unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Altered Level of Consciousness
E. Overall, how would you rate the patient's level of consciousness?
E1. Alert (Normal)
E2. Vigilant (hyperalert) or Lethargic (drowsy, easily aroused) or Stupor (difficult to arouse) or Coma
(unarousable)

Adapted with permission from: Inouye SK et al, Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Annals of Internal Medicine. 1990;
113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide, Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced without permission.

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section GG.

Date

Functional Abilities and Goals.

GG0100. Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
3. Independent - Patient completed the activities by him/herself, with or
without an assistive device, with no assistance from a helper.
2. Needed Some Help - Patient needed partial assistance from another person
to complete activities.
1. Dependent - A helper completed the activities for the patient.
8. Unknown
9. Not Applicable

Enter Codes in Boxes.
B. Indoor Mobility (Ambulation): Code the patient's
need for assistance with walking from room to room
(with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or
injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair.
B. Motorized wheelchair or scooter.
C. Mechanical lift.
Z. None of the above.

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Do not use codes 07, 09, or 88 to code
discharge goal(s).
CODING:
Safety and Quality of Performance - If helper assistance
is required because patient's performance is unsafe or of
poor quality, score according to amount of assistance
provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by
him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper SETS UP or
CLEANS UP; patient completes activity. Helper assists
only prior to or following the activity.
04. Supervision or touching assistance - Helper
provides VERBAL CUES or TOUCHING/ STEADYING
assistance as patient completes activity. Assistance
may be provided throughout the activity or
intermittently.
03. Partial/moderate assistance - Helper does LESS
THAN HALF the effort. Helper lifts, holds or supports
trunk or limbs, but provides less than half the effort.
02. Substantial/maximal assistance - Helper does
MORE THAN HALF the effort. Helper lifts or holds
trunk or limbs and provides more than half the effort.
01. Dependent - Helper does ALL of the effort. Patient
does none of the effort to complete the activity. Or,
the assistance of 2 or more helpers is required for
the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical condition or safety
concerns

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring
food to the mouth and swallow food once the meal
is presented on a table/tray. Includes modified food
consistency.
B. Oral hygiene: The ability to use suitable items to
clean teeth. [Dentures (if applicable): The ability to
remove and replace dentures from and to the
mouth, and manage equipment for soaking and
rinsing them.]
C. Toileting hygiene: The ability to maintain perineal
hygiene, adjust clothes before and after using the
toilet, commode, bedpan or urinal. If managing an
ostomy, include wiping the opening but not
managing equipment.
D. Wash upper body: The ability to wash, rinse, and
dry the face, hands, chest, and arms while sitting in
a chair or bed.

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Section GG.

Identifier

Date

Functional Abilities and Goals.

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Do not use codes 07, 09, or 88 to code
discharge goal(s).
CODING:
Safety and Quality of Performance - If helper
assistance is required because patient's
performance is unsafe or of poor quality, score
according to amount of assistance provided.
Activities may be completed with or without
assistive devices.
06. Independent - Patient completes the
activity by him/herself with no assistance
from a helper.
05. Setup or clean-up assistance - Helper
SETS UP or CLEANS UP; patient completes
activity. Helper assists only prior to or
following the activity.
04. Supervision or touching assistance Helper provides VERBAL CUES or
TOUCHING/ STEADYING assistance as
patient completes activity. Assistance may
be provided throughout the activity or
intermittently.
03. Partial/moderate assistance - Helper
does LESS THAN HALF the effort. Helper
lifts, holds or supports trunk or limbs, but
provides less than half the effort.
02. Substantial/maximal assistance - Helper
does MORE THAN HALF the effort. Helper
lifts or holds trunk or limbs and provides
more than half the effort.
01. Dependent - Helper does ALL of the effort.
Patient does none of the effort to complete
the activity. Or, the assistance of 2 or more
helpers is required for the patient to
complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable
88. Not attempted due to medical condition
or safety concerns

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left
and right side, and return to lying on back.
B. Sit to lying: The ability to move from sitting on side of bed to
lying flat on the bed.
C. Lying to sitting on side of bed: The ability to safely move
from lying on the back to sitting on the side of the bed with
feet flat on the floor, and with no back support.
D. Sit to stand: The ability to safely come to a standing position
from sitting in a chair or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to safely transfer to
and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to safely get on and off a toilet or
commode.
H1. Does the patient walk?
0. No, and walking goal is not clinically
indicated
Skip to GG0170Q1. Does the
patient use a wheelchair/scooter?
1. No, and walking goal is clinically indicated
Code the patient's Discharge Goal(s) for items
GG0170I, J, and K. For Admission Performance,
skip to GG0170Q1. Does the patient use a
wheelchair/scooter?
2. Yes

Continue to GG0170I. Walk 10 feet

I. Walk 10 feet: Once standing, the ability to walk at least 10 feet
in a room, corridor or similar space.
J. Walk 50 feet with two turns: Once standing, the ability to
walk 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150
feet in a corridor or similar space.
Q1. Does the patient use a wheelchair/scooter?
0. No
Skip to H0350. Bladder Continence
1. Yes
Continue to GG0170R. Wheel
50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/
scooter, the ability to wheel at least 50 feet and make two
turns.
RR1. Indicate the type of wheelchair/scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the
ability to wheel at least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair/scooter used.
1. Manual
2. Motorized

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section H.

Date

Bladder and Bowel.

H0350. Bladder Continence (3-day assessment period)
Enter Code

Bladder continence - Select the one category that best describes the patient..
0. Always continent (no documented incontinence)
1. Stress incontinence only
2. Incontinent less than daily (e.g., once or twice during the 3-day assessment period)
3. Incontinent daily (at least once a day)
4. Always incontinent
5. No urine output (e.g., renal failure)
9. Not applicable (e.g., indwelling catheter)

H0400. Bowel Continence (3-day assessment period)
Enter Code

Bowel continence - Select the one category that best describes the patient..
0. Always continent
1. Occasionally incontinent (one episode of bowel incontinence)
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)
3. Always incontinent (no episodes of continent bowel movements)
9. Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days.

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section I.

Date

Active Diagnoses.

I0050. Indicate the patient's primary medical condition category.
Enter Code

Indicate the patient's primary medical condition category.
1. Acute onset respiratory condition (e.g., aspiration and specified bacterial pneumonias)
2. Chronic respiratory condition (e.g., chronic obstructive pulmonary disease)
3. Acute onset and chronic respiratory conditions
4. Chronic cardiac condition (e.g., heart failure)
5. Other medical condition If “other medical condition”, enter the ICD code in the boxes.
I0050A.

Comorbidities and Co-existing Conditions
Check all that apply.
Cancers.
I0101. Severe and Metastatic Cancers
Heart/Circulation.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Genitourinary
I1501. Chronic Kidney Disease, Stage 5
I1502. Acute Renal Failure
Infections
I2101. Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock
I2600. Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis
Metabolic
I2900. Diabetes Mellitus (DM)
Musculoskeletal
I4100. Major Lower Limb Amputation (e.g., above knee, below knee)
Neurological
I4501. Stroke
I4801. Dementia
I4900. Hemiplegia or Hemiparesis
I5000. Paraplegia
I5101. Complete Tetraplegia
I5102. Incomplete Tetraplegia
I5110. Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)
I5200. Multiple Sclerosis (MS)
I5250. Huntington's Disease
I5300. Parkinson's Disease
I5450. Amyotrophic Lateral Sclerosis
I5460. Locked-In State
I5470. Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain
Nutritional
I5601. Malnutrition (protein or calorie)
I5602. At Risk for Malnutrition
None of the Above
I7900. None of the above

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Section K.

Identifier

Date

Swallowing/Nutritional Status.

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since admission..
inches

pounds

B. Weight (in pounds). Base weight on most recent measure in last 3 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off)..

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section M.

Date

Skin Conditions.

Report based on highest stage of existing ulcer(s) at its worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcer(s).
Enter Code

Does this patient have one or more unhealed pressure ulcer(s) at Stage 1 or higher?
0. No
Skip to O0100. Special Treatments, Procedures, and Programs.
1. Yes
Continue to M0300. Current Number of Unhealed Pressure Ulcers at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers 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.
Number of Stage 1 pressure ulcers

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

Enter Number

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

Enter Number

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

Enter Number

E. Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device.
1. Number of unstageable pressure ulcers due to non-removable dressing/device
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
G. Unstageable - Deep tissue injury: Suspected deep tissue injury in evolution.
Enter Number

1. Number of unstageable pressure ulcers with suspected deep tissue injury in evolution

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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Patient

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0100. Special Treatments, Procedures, and Programs
Check all the treatments at admission. For dialysis, check if it is part of the patient's treatment plan.
Check all that apply.
Respiratory Treatments
F3. Invasive Mechanical Ventilator: weaning
F4. Invasive Mechanical Ventilator: non-weaning
G. Non-invasive Ventilator (BIPAP, CPAP)
Other Treatments
J. Dialysis
N. Total Parenteral Nutrition
None of the Above
Z. None of the above

O0250. Influenza Vaccine - Refer to current version of LTCH Quality Reporting Program Manual for current influenza season and
reporting period..
Enter Code

A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No... Skip to O0250C. If influenza vaccine not received, state reason.
1. Yes
Continue to O0250B. Date influenza vaccine received.
B. Date influenza vaccine received

_

_
Month
Enter Code

Complete date and skip to Z0400. Signature of Persons Completing the Assessment

Day

Year

C. If influenza vaccine not received, state reason:
1. Patient not in this facility during this year's influenza vaccination season
2. Received outside of this facility
3. Not eligible - medical contraindication
4. Offered and declined
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage
9. None of the above

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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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.
Date Section
Signature
Title.
Sections.
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

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

Year

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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. The time required to complete this information collection is estimated to average 30 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.

Admission Long-Term Care Hospital (LTCH) Continuity Assessment Record & Evaluation (CARE) Data Set, v3.00
Effective April 1, 2016

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