CMS-10409 LTCH Care Data Set Planned Discharge

Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 4.00
PATIENT ASSESSMENT FORM - PLANNED DISCHARGE

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

Year

Day

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.
_

_
Month

Day

Year

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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):

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Patient

Identifier

Section A

Date

Administrative Information

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.

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 .

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Patient

Identifier

Section A

Date

Administrative Information

A2110. Discharge Location
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
12.
98.

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
Discharged Against Medical Advice
Other

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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
1. Yes
Skip to GG0130, Self-Care

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 and Non-Verbal Content (3-day assessment period)
Enter Code

Understanding Verbal and Non-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

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Patient

Identifier

Section C

Date

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©) (within the last 7 days)
A. Acute Onset Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously
present, does not
fluctuate
2. Behavior present,
fluctuates (comes and
goes, changes in
severity)

Enter Code in Boxes.
B. Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling
or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject
to subject)?
D. Altered Level of Consciousness - Did the patient have altered level of consciousness as indicated
by any of the following criteria?
■ vigilant - startled easily to any sound or touch
■ lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch
■ stuporous - very difficult to arouse and keep aroused for the interview
■ comatose - could not be aroused

Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

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Patient

Identifier

Section D

Date

Mood

D0150. Patient Health Questionnaire 2 (PHQ-2©)
Say to patient: “Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
0. No (enter 0 in column 2)
0. Never or 1 day
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
9. No response (leave column 2 blank)
2. 7-11 days (half or more of the days)
3. 12-14 days (nearly every day)

1.
Symptom
Presence

2.
Symptom
Frequency

Enter Scores in Boxes

A. Little interest or pleasure in doing things?
B. Feeling down, depressed, or hopeless?
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

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Patient

Section E

Identifier

Date

Behavioral Symptoms

E0200. Behavioral Symptom - Presence & Frequency
Note presence of symptoms and their frequency.
Coding:
0. Behavior not exhibited
1. Behavior of this type
occurred 1 to 3 days
2. Behavior of this type
occurred 4 to 6 days,
but less than daily
3. Behavior of this type
occurred daily

Enter Code in Boxes.
A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing,
scratching, grabbing, abusing others sexually)
B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at
others, cursing at others)
C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting
or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing
food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)

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Patient

Section GG

Identifier

Date

Functional Abilities and Goals

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If an activity was not attempted at
discharge, code the reason.
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 and/or touching/steadying and/or contact
guard 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.

3.
Discharge
Performance
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or
liquid to the mouth and swallow food and/or liquid once the
meal is placed before the patient.
B. Oral hygiene: The ability to use suitable items to clean teeth.
Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking
and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene,
adjust clothes before and after voiding or having a bowel
movement. 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.

If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not
perform this activity prior to the current illness,
exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g.,
lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety
concerns

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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 discharge for each activity using the 6-point scale. If an activity was not attempted at
discharge, code the reason.
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 and/or touching/steadying and/or contact guard
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 - Not attempted and the patient did not
perform this activity prior to the current illness,
exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g.,
lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety
concerns

3.
Discharge
Performance.
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 on the bed.
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 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 come to a standing position from
sitting in a chair, wheelchair, or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and
from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or
commode.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet
in a room, corridor, or similar space. If discharge performance is
coded 07, 09, 10, or 88
Skip to GG0170Q3, Does the patient
use a wheelchair and/or scooter?
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.
Q3. Does the patient use a wheelchair and/or
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.
RR3. Indicate the type of wheelchair or 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.
SS3. Indicate the type of wheelchair or scooter
used.
1. Manual
2. Motorized

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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)

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Patient

Identifier

Section J

Date

Health Conditions

J1800. Any Falls Since Admission .
Enter Code

Has the patient had any falls since admission?
0. No
Skip to K0520, Nutritional Approaches
1. Yes
Continue to J1900, Number of Falls Since Admission .

J1900. Number of Falls Since Admission .
Coding:
0. None
1. One
2. 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

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Patient

Section K

Identifier

Date

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that were performed during the last 7 days.
2.
Performed
during the last
7 days
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube - nasogastric or abdominal (e.g., PEG)
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

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Patient

Identifier

Section M

Date

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N2005, Medication Intervention
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries 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.
1. Number of Stage 1 pressure injuries

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.- If 0

Enter Number

Skip to M0300C, Stage 3.

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
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.

Enter Number

1. Number of Stage 3 pressure ulcers - If 0
Enter Number

Skip to M0300D, Stage 4.

2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
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.

Enter Number

1. Number of Stage 4 pressure ulcers - If 0
Enter Number

Skip to M0300E, Unstageable - Non-removable dressing/device.

2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0
Slough and/or eschar.

Skip to M0300F, Unstageable -

2. Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at
the time of admission.
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar If 0
Unstageable - Deep tissue injury.

Skip to M0300G,

2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission.

M0300 continued on next page.

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Patient

Identifier

Section M

Date

Skin Conditions

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued.
Enter Number

G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0
Intervention

Enter Number

Skip to N2005, Medication

2. Number of these unstageable pressure injuries that were present upon admission - enter how many were noted at the time
of admission.

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Patient

Identifier

Section N

Date

Medications

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. NA - There were no potential clinically significant medication issues identified since admission or patient is not taking
any medications

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
4.
Performed
during the last
14 days
Check all that apply
Cancer Treatments
A. Chemotherapy (if checked, please specify below)
A2a. IV
A3a. Oral
A10a. Other
B. Radiation.
Respiratory Treatments.
C. Oxygen Therapy (if checked, please specify below)
C2a. Continuous
C3a. Intermittent
D. Suctioning (if checked, please specify below)
D2a. Scheduled
D3a. As needed
E. Tracheostomy Care.
G. Non-invasive Mechanical Ventilator (BiPAP/CPAP) (if checked, please specify below)
G2a. BiPAP
G3a. CPAP
Other Treatments.
H. IV Medications (if checked, please specify below)
H2a. Vasoactive medications (i.e., continuous infusions of vasopressors or inotropes)
H3a. Antibiotics
H4a. Anticoagulation
H10a. Other
I. Transfusions
J. Dialysis (if checked, please specify below)
J2a. Hemodialysis
J3a. Peritoneal dialysis
O. IV Access (if checked, please specify below)
O2a. Peripheral IV
O3a. Midline
O4a. Central line (e.g., PICC, tunneled, port)
O10a. Other
None of the Above
Z. None of the above

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0200. Ventilator Liberation Rate.
Enter Code

A. Invasive Mechanical Ventilator: Liberation Status at Discharge
0. Not fully liberated at discharge (i.e., patient required partial or full invasive mechanical ventilation support within 2 calendar days
prior to discharge)
1. Fully liberated at discharge (i.e., patient did not require any invasive mechanical ventilation support for at least 2 consecutive
calendar days immediately prior to discharge)
9. NA (code only if the patient was non-weaning or not ventilated on admission [O0150A=2 or 0 on Admission Assessment])

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

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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.
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

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Day

Year

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