Appendix A: Master List

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Overview

Sheet1
Sheet2

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Sheet 1: Sheet1

Item No.	Description	Admission	Planned Discharge	Unplanned Discharge	Expired	Rationale for Inclusion as a Required Item for April 1, 2018 Data Collection	New for V4.00	Required for Burden
A0050	Type of Record	R	R	R	R	System cannot accept record without response	N	Y
A0100A	National Provider Identifier (NPI)	R	R	R	R	—	N	Y
A0100B	CMS Certification Number (CCN)	R	R	R	R	—	N	Y
A0100C	State Medicaid provider number	RIAV	RIAV	RIAV	RIAV	—	N	Y
A0200	Type of provider	R	R	R	R	System cannot accept record without response	N	Y
A0210	Assessment Reference Date	R	R	R	R	System cannot accept record without response	N	Y
A0220	Admission Date	R	R	R	R	System cannot accept record without response	N	Y
A0250	Reason for Assessment	R	R	R	R	System cannot accept record without response	N	Y
A0270	Discharge Date (Date of Death on Expired form)	N/A	R	R	R	System cannot accept record without response	N	Y
A0500A	Patient first name	R	R	R	R	Required, however, system accepts default response of hyphen or dash	N	Y
A0500B	Patient middle initial	RIAV	RIAV	RIAV	RIAV	—	N	Y
A0500C	Patient last name	R	R	R	R	System cannot accept record without response	N	Y
A0500D	Patient name suffix	RIAV	RIAV	RIAV	RIAV	—	N	Y
A0600A	Social Security Number	R	R	R	R	Required, however, system accepts default response of hyphen or dash	N	Y
A0600B	Medicare/railroad insurance number	RIAV	RIAV	RIAV	RIAV	—	N	Y
A0700	Medicaid number	RIAV	RIAV	RIAV	RIAV	—	N	Y
A0800	Gender	R	R	R	R	System cannot accept record without response	N	Y
A0900	Birth date	R	R	R	R	Birth year required	N	Y
A1000A	Race/Ethnicity: American Indian or Alaska Native	RIAV	RIAV	RIAV	RIAV	—	N	Y
A1000B	Race/Ethnicity: Asian	RIAV	RIAV	RIAV	RIAV	—	N	N
A1000C	Race/Ethnicity: Black or African American	RIAV	RIAV	RIAV	RIAV	—	N	N
A1000D	Race/Ethnicity: Hispanic or Latino	RIAV	RIAV	RIAV	RIAV	—	N	N
A1000E	Race/Ethnicity: Native Hawaiian/Pacific Islander	RIAV	RIAV	RIAV	RIAV	—	N	N
A1000F	Race/Ethnicity: White	RIAV	RIAV	RIAV	RIAV	—	N	N
A1100A	Does the patient need or want an interpreter	RIAV	N/A	N/A	N/A	—	N	Y
A1100B	Preferred language	RIAV	N/A	N/A	N/A	—	N	Y
A1200	Marital status	RIAV	N/A	N/A	N/A	—	N	Y
A1400A	Payer Information: Current Payment Source(s): Medicare (traditional FFS)	RIAV	RIAV	RIAV	RIAV	—	N	Y
A1400B	Payer Information: Current Payment Source(s): Medicare (managed care, Part C, Medicare Advantage)	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400C	Payer Information: Current Payment Source(s): Medicaid (traditional FFS)	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400D	Payer Information: Current Payment Source(s): Medicaid (managed care)	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400E	Payer Information: Current Payment Source(s): Workers' compensation	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400F	Payer Information: Current Payment Source(s): Title programs (e.g., III, V, or XX)	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400G	Payer Information: Current Payment Source(s): Other government (TRICARE, VA)	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400H	Payer Information: Current Payment Source(s):Private insurance/Medigap	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400I	Payer Information: Current Payment Source(s): Private managed care	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400J	Payer Information: Current Payment Source(s): Self-pay	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400K	Payer Information: Current Payment Source(s): No Payer Source	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400X	Payer Information: Current Payment Source(s): Unknown	RIAV	RIAV	RIAV	RIAV	—	N	N
A1400Y	Payer Information: Current Payment Source(s): Other	RIAV	RIAV	RIAV	RIAV	—	N	N
A1802	Admitted from	R	N/A	N/A	N/A	—	N	Y
A2110	Discharge location	N/A	R	R	N/A	—	N	Y
B0100	Comatose	R	R	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	Y
B0200	Hearing	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
B1000	Vision	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
BB0700	Expression of Ideas and Wants	R	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	N	Y
BB0800	Understanding Verbal and Non-Verbal Content	R	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	N	Y
C0100	Should BIMS be Conducted?	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0200	Repetition of Three Words	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0300A	Temporal Orientation Able to report correct year	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0300B	Temporal Orientation Able to report correct month	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0300C	Temporal Orientation Able to report correct day of the week	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0400A	Recall Able to recall "sock"	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0400B	Recall Able to recall "blue"	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0400C	Recall Able to recall "bed"	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C0500	BIMS Summary Score	R	N/A	N/A	N/A	Proposed standardized assessment data element.	Y	Y
C1310A	Signs and Symptoms of Delirium (from CAM©): Acute Onset Mental Status Change - Is there evidence of an acute change in mental status from the patient's baseline?	R	R	R	N/A	Proposed standardized assessment data element. Required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	Y	Y
C1310B	Signs and Symptoms of Delirium (from CAM©): Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?	R	R	R	N/A	Proposed standardized assessment data element. Required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	Y	Y
C1310C	Signs and Symptoms of Delirium (from CAM©): 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)?	R	R	R	N/A	Proposed standardized assessment data element. Required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	Y	Y
C1310D	Signs and Symptoms of Delirium (from CAM©): 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	R	R	R	N/A	Proposed standardized assessment data element. Required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	Y	Y
D0150A	Patient Health Questionnaire 2 (PHQ-2 ©): Little interest or pleasure in doing things?	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
D0150B	Patient Health Questionnaire 2 (PHQ-2 ©): Feeling down, depressed, or hopeless?	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
E0200A	Behavioral Symptom - Presence & Frequency: Physical behavioral symptoms directed toward others	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
E0200B	Behavioral Symptom - Presence & Frequency: Verbal behavioral symptoms directed toward others	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
E0200C	Behavioral Symptom - Presence & Frequency: Other behavioral symptoms not directed toward others	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
GG0100B	Prior Functioning: Everyday Activities. Indoor Mobility (Ambulation)	R	N/A	N/A	N/A	Part of covariate calculation for LTCH Mobility QM.	N	Y
GG0110A	Prior Device Use: Manual wheelchair	R	N/A	N/A	N/A	Covariate for LTCH Function Mobility QM.	N	Y
GG0110B	Prior Device Use: Motorized wheelchair and/or scooter	R	N/A	N/A	N/A		N	N
GG0110C	Prior Device Use: Mechanical lift	R	N/A	N/A	N/A		N	N
GG0110Z	Prior Device Use: None of the above	R	N/A	N/A	N/A		N	N
GG0130A1	Self Care: Eating: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130A2	Self Care: Eating: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	Y
GG0130A3	Self Care: Eating: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130B1	Self Care: Oral hygiene: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130B2	Self Care: Oral hygiene: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0130B3	Self Care: Oral hygiene: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130C1	Self Care: Toileting hygiene: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130C2	Self Care: Toileting: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0130C3	Self Care: Toileting hygiene: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130D1	Self Care: Wash upper body: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0130D2	Self Care: Wash upper body: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0130D3	Self Care: Wash upper body: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170A1	Functional mobility: Roll left and right: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170A2	Functional mobility: Roll left and right: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170A3	Functional mobility: Roll left and right: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170B1	Functional mobility: Sit to lying: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170B2	Functional mobility: Sit to lying: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170B3	Functional mobility: Sit to lying: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170C1	Functional mobility: Lying to sitting on side of bed: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170C2	Functional mobility: Lying to sitting on side of bed: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170C3	Functional mobility: Lying to sitting on side of bed: Performance	N/A	N/A	R	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	N
GG0170D1	Functional mobility: Sit to stand: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170D2	Functional mobility: Sit to stand: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170D3	Functional mobility: Sit to stand: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170E1	Functional mobility: Chair/bed-to-chair transfer: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170E2	Functional mobility: Chair/bed-to-chair transfer: Goal (Only 1 Goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170E3	Functional mobility: Chair/bed-to-chair transfer: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170F1	Functional mobility: Toilet transfer: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170F2	Functional mobility: Toilet transfer: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170F3	Functional mobility: Toilet transfer: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170I1	Functional mobility: Walk 10 feet: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170I2	Functional mobility: Walk 10 feet: Goal (Only 1 Goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170I3	Functional mobility: Walk 10 feet: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170J1	Functional mobility: Walk 50 feet with two turns: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170J2	Functional mobility: Walk 50 feet with two turns: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170J3	Functional mobility: Walk 50 feet with two turns: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170K1	Functional mobility: Walk 150 feet: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170K2	Functional mobility: Walk 150 feet: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170K3	Functional mobility: Walk 150 feet: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Used to calculate change in mobility value for the LTCH Mobility QM.	N	Y
GG0170Q1	Functional mobility: Does the patient use a wheelchair and/or scooter?	R	N/A	N/A	N/A	Item added to reduce burden. If GG0170Q1=0, skip to H0350 Bladder Continence.	N	Y
GG0170Q3	Functional mobility: Does the patient use a wheelchair and/or scooter?	R	N/A	N/A	N/A	Item added to reduce burden. If GG0170Q3=0, skip to H0350 Bladder Continence.	N	Y
GG0170R1	Functional mobility: Wheel 50 feet with two turns: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170R2	Functional mobility: Wheel 50 feet with two turns: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170R3	Functional mobility: Wheel 50 feet with two turns: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170RR1	Functional mobility: Indicate the type of wheelchair or scooter used	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170RR3	Functional mobility: Indicate the type of wheelchair or scooter used	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170S1	Functional mobility: Wheel 150 feet: Performance	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170S2	Functional mobility: Wheel 150 feet: Goal (Only 1 goal required)	R	N/A	N/A	N/A	Reporting 1 more goals provides documentation that function is included in the patient's care plan.	N	N
GG0170S3	Functional mobility: Wheel 150 feet: Performance	N/A	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170SS1	Functional mobility: Indicate the type of wheelchair or scooter used	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
GG0170SS3	Functional mobility: Indicate the type of wheelchair or scooter used	R	N/A	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM.	N	Y
H0350	Bladder Continence	R	R	N/A	N/A	Standardized assessment data required for submission as part of the Function Process QM. Covariate for Function Mobility QM.	N	Y
H0400	Bowel Continence	R	N/A	N/A	N/A	Part of covariate calculation for PU measure	N	Y
I0050	Indicate the patient's primary medical condition	R	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	Y
I0050A	Indicate the patient's primary medical condition (ICD)	R	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I0103	Comorbidities and Co-existing Conditions: Metastatic Cancer	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM. Covariate for Function Mobility QM.	Y	Y
I0104	Comorbidities and Co-existing Conditions: Severe Cancer	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM. Covariate for Function Mobility QM.	Y	N
I0605	Comorbidities and Co-existing Conditions: Severe Left Systolic/Ventricular Dysfunction (known ejection fraction ≤ 30%)	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I5455	Comorbidities and Co-existing Conditions: Other Progressive Neuromuscular Disease	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I5480	Comorbidities and Co-existing Conditions: Other Severe Neurological Injury, Disease, or Dysfunction	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I7100	Comorbidities and Co-existing Conditions: Lung Transplant	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I7101	Comorbidities and Co-existing Conditions: Heart Transplant	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I7102	Comorbidities and Co-existing Conditions: Liver Transplant	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I7103	Comorbidities and Co-existing Conditions: Kidney Transplant	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I7104	Comorbidities and Co-existing Conditions: Bone Marrow Transplant	RIAV	N/A	N/A	N/A	Proposed covariate for Ventilator Weaning Outcome QM.	Y	N
I0900	Comorbidities and Co-existing Conditions: Peripheral vascular disease (PVD) or Peripheral Arterial Disease (PAD)	RIAV	N/A	N/A	N/A	Part of covariate calculation for PU measure	N	N
I1501	Comorbidities and Co-existing Conditions: Chronic Kidney Disease, Stage 5	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I1502	Comorbidities and Co-existing Conditions: Acute Renal Failure	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I2101	Comorbidities and Co-existing Conditions: Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I2600	Comorbidities and Co-existing Conditions: Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I2900	Comorbidities and Co-existing Conditions: Diabetes mellitus (DM)	RIAV	N/A	N/A	N/A	Part of covariate calculation for PU measure. Covariate for LTCH Mobility QM.	N	N
I4100	Comorbidities and Co-existing Conditions: Major Limb Amputation	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I4501	Comorbidities and Co-existing Conditions: Stroke	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I4801	Comorbidities and Co-existing Conditions: Dementia	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I4900	Comorbidities and Co-existing Conditions: Hemiplegia or Hemiparesis	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I5000	Comorbidities and Co-existing Conditions: Paraplegia	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I5101	Comorbidities and Co-existing Conditions: Complete Tetraplegia	RIAV	N/A	N/A	N/A	Exclusion for the LTCH Mobility QM. Covariate for Function Mobility QM.	N	N
I5102	Comorbidities and Co-existing Conditions: Incomplete Tetraplegia	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I5110	Comorbidities and Co-existing Conditions: Other Spinal Cord Disorder/Injury	RIAV	N/A	N/A	N/A	Covariate for Function Mobility QM.	N	N
I5200	Comorbidities and Co-existing Conditions: Multiple Sclerosis (MS)	RIAV	N/A	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	N
I5250	Comorbidities and Co-existing Conditions: Huntington's Disease	RIAV	N/A	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	N
I5300	Comorbidities and Co-existing Conditions: Parkinson's Disease	RIAV	N/A	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	N
I5450	Comorbidities and Co-existing Conditions: Amyotrophic Lateral Sclerosis	RIAV	N/A	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	N
I5460	Comorbidities and Co-existing Conditions: Locked-In State	RIAV	N/A	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	N
I5470	Comorbidities and Co-existing Conditions: Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain	RIAV	N/A	N/A	N/A	Exclusion criterion for the LTCH Mobility QM.	N	N
I5601	Comorbidities and Co-existing Conditions: Malnutrition (protein or calorie)	RIAV	N/A	N/A	N/A	Part of covariate calculation for LTCH Mobility QM.	N	N
I5602	Comorbidities and Co-existing Conditions: At risk for malnutrition	RIAV	N/A	N/A	N/A	Part of covariate calculation for LTCH Mobility QM.	N	N
I7900	Comorbidities and Co-existing Conditions: None of the above	RIAV	N/A	N/A	N/A	None of the comorbidity covariates apply to this patient.	N	N
J1800	Any Falls Since Admission	N/A	R	R	R	Part of numerator calculation for Falls measure	N	Y
J1900A	Number of Falls Since Admission - No Injury	N/A	RIAV	RIAV	RIAV	Part of numerator calculation for Falls measure	N	Y
J1900B	Number of Falls Since Admission - Injury (except major)	N/A	RIAV	RIAV	RIAV	Part of numerator calculation for Falls measure	N	N
J1900C	Number of Falls Since Admission - Major Injury	N/A	R	R	R	Part of numerator calculation for Falls measure	N	N
K0200A	Height (in inches)	R	N/A	N/A	N/A	Part of covariate calculation for PU measure	N	Y
K0200B	Weight (in pounds)	R	N/A	N/A	N/A	Part of covariate calculation for PU measure	N	Y
K0520A	Nutritional Approaches: Parenteral/IV feeding	R	R	N/A	N/A	Proposed standardized assessment data element. Covariate for Function Mobility QM.	Y	Y
K0520B	Nutritional Approaches: Feeding tube	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
K0520C	Nutritional Approaches: Mechanically altered diet	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
K0520D	Nutritional Approaches: Therapeutic diet	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	Y
K0520Z	Nutritional Approaches: None of the above	R	R	N/A	N/A	Proposed standardized assessment data element.	Y	N
M0210	Unhealed Pressure Ulcers/Injuries	R	R	R	N/A	System cannot accept record without response	N	Y
M0300A	Stage 1: Number of stage 1 pressure injuries	R	R	R	N/A	System cannot accept record without response	N	Y
M0300B1	Stage 2: Number of stage 2 pressure ulcers	R	R	R	N/A	Used for PU Measure consistency checks	N	Y
M0300B2	Stage 2: Number of these stage 2 pressure ulcers that were present upon admission	N/A	R	R	N/A	System cannot accept record without response	N	Y
M0300C1	Stage 3: Number of stage 3 pressure ulcers	R	R	R	N/A	System cannot accept record without response	N	Y
M0300C2	Stage 3: Number of these stage 3 pressure ulcers that were present upon admission	N/A	R	R	N/A	System cannot accept record without response	N	Y
M0300D1	Stage 4: Number of stage 4 pressure ulcers	R	R	R	N/A	System cannot accept record without response	N	Y
M0300D2	Stage 4: Number of these stage 4 pressure ulcers that were present upon admission	N/A	R	R	N/A	System cannot accept record without response	N	Y
M0300E1	Unstageable - Non-removable dressing/device: Number of unstageable pressure ulcers/injuries due to non-removable dressing/device	R	R	R	N/A	System cannot accept record without response	N	Y
M0300E2	Unstageable - Non-removable dressing: Number of these unstageable pressure ulcers/injuries that were present upon admission	N/A	R	R	N/A	System cannot accept record without response	N	Y
M0300F1	Unstageable - Slough and/or eschar: Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar	R	R	R	N/A	System cannot accept record without response	N	Y
M0300F2	Unstageable - Slough and/or eschar: Number of these unstageable pressure ulcers that were present upon admission	N/A	R	R	N/A	System cannot accept record without response	N	Y
M0300G1	Unstageable - Deep tissue injury: Number of unstageable pressure injuries presenting as deep tissue injury	R	R	R	N/A	System cannot accept record without response	N	Y
M0300G2	Unstageable - Deep tissue injury: Number of these unstageable pressure injuries that were present upon admission	N/A	R	R	N/A	System cannot accept record without response	N	Y
N2001	Drug Regimen Review	R	N/A	N/A	N/A	Proposed data element for Drug Regimen Review QM.	Y	Y
N2003	Medication Follow-up	R	N/A	N/A	N/A	Proposed data element for Drug Regimen Review QM.	Y	Y
N2005	Medication Intervention	N/A	R	R	R	Proposed data element for Drug Regimen Review QM.	Y	Y
O0100A	Special Treatments, Procedures, and Programs: Chemotherapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	Y
O0100A2a	Special Treatments, Procedures, and Programs: IV Chemotherapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O010A3a	Special Treatments, Procedures, and Programs: Oral Chemotherapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100A10a	Special Treatments, Procedures, and Programs: Other Chemotherapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100B	Special Treatments, Procedures, and Programs: Radiation	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	Y
O0100C	Special Treatments, Procedures, and Programs: Oxygen Therapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	Y
O0100C2a	Special Treatments, Procedures, and Programs: Continuous Oxygen Therapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100C3a	Special Treatments, Procedures, and Programs: Intermittent Oxygen Therapy	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100D	Special Treatments, Procedures, and Programs: Suctioning	RIAV	RIAV	RIAV	N/A	Proposed standardized assessment data element.	Y	Y
O0100D2a	Special Treatments, Procedures, and Programs: Scheduled Suctioning	RIAV	RIAV	RIAV	N/A	Proposed standardized assessment data element.	Y	N
O0100D3a	Special Treatments, Procedures, and Programs: As needed Suctioning	RIAV	RIAV	RIAV	N/A	Proposed standardized assessment data element.	Y	N
O0100E	Special Treatments, Procedures, and Programs: Tracheostomy Care	RIAV	RIAV	RIAV	N/A	Proposed standardized assessment data element.	Y	Y
O0100G	Special Treatments, Procedures, and Programs: Non-invasive Mechanical Ventilator (BiPAP/CPAP)	RIAV	RIAV	N/A	N/A	Inclusion criterion for the LTCH Mobility QM. Proposed standardized assessment data element.	Y	Y
O0100G2a	Special Treatments, Procedures, and Programs: Non-invasive Mechanical Ventilator (BiPAP/CPAP) - BiPAP	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100G3a	Special Treatments, Procedures, and Programs: Non-invasive Mechanical Ventilator (BiPAP/CPAP) - CPAP	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100H	Special Treatments, Procedures, and Programs: IV Medications	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	Y
O0100H2a	Special Treatments, Procedures, and Programs: Vasoactive medications	RIAV	RIAV	N/A	N/A	Proposed data element for Ventilator Weaning Outcome QM. Proposed standardized assessment data element.	Y	N
O0100H3a	Special Treatments, Procedures, and Programs: Vasoactive medications - Antibiotics	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100H4a	Special Treatments, Procedures, and Programs: Vasoactive medications -Anticoagulation	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100H10a	Special Treatments, Procedures, and Programs: Vasoactive medications - Other	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100I	Special Treatments, Procedures, and Programs: Transfusions	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	Y
O0100J	Special Treatments, Procedures, and Programs: Dialysis	RIAV	RIAV	N/A	N/A	Proposed data element for Ventilator Weaning Outcome QM. Inclusion criterion for the LTCH Mobility QM. Proposed standardized assessment data element.	Y	Y
O0100J2a	Special Treatments, Procedures, and Programs: Dialysis - Hemodialysis	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100J3a	Special Treatments, Procedures, and Programs: Dialysis - Peritoneal dialysis	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100O	Special Treatments, Procedures, and Programs: IV Access	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	Y
O0100O2a	Special Treatments, Procedures, and Programs: IV Access - Peripheral IV	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100O3a	Special Treatments, Procedures, and Programs: IV Access - Midline	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100O4a	Special Treatments, Procedures, and Programs: IV Access - Central line	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100O10a	Special Treatments, Procedures, and Programs: IV Access - Other	RIAV	RIAV	N/A	N/A	Proposed standardized assessment data element.	Y	N
O0100Z	Special Treatments, Procedures, and Programs: None of the above	RIAV	RIAV	RIAV	N/A	None of the comorbidity covariates for special treatments, procedures, and programs apply to this patient.	Y	N
O0150A	SBT by Day 2 of the LTCH Stay: Invasive Mechanical Ventilation Support upon Admission to the LTCH	R	N/A	N/A	N/A	Proposed data element for Ventilator Weaning Process QM. Inclusion criterion for the LTCH Mobility QM.	Y	Y
O0150B	SBT by Day 2 of the LTCH Stay: Assessed for readiness for SBT by day 2 of the LTCH stay	R	N/A	N/A	N/A	Proposed data element for Ventilator Weaning Process QM.	Y	Y
O0150C	SBT by Day 2 of the LTCH Stay: Deemed medically ready for SBT by day 2 of the LTCH stay	R	N/A	N/A	N/A	Proposed data element for Ventilator Weaning Process QM.	Y	Y
O0150D	SBT by Day 2 of the LTCH Stay: Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically unready for SBT by day 2 of the LTCH stay?	R	N/A	N/A	N/A	Proposed data element for Ventilator Weaning Process QM.	Y	Y
O0150E	SBT by Day 2 of the LTCH Stay: SBT performed by day 2 of the LTCH stay	R	N/A	N/A	N/A	Proposed data element for Ventilator Weaning Process QM.	Y	Y
O0200	Ventilator Liberation Rate	N/A	R	N/A	N/A	Proposed data element for Ventilator Weaning Outcome QM	Y	Y
O0250A	Influenza vaccine - did patient receive influenza vaccine in this facility for this year's influenza vaccination season	R	R	R	R	Part of numerator calculation for Influenza vaccination measure	N	Y
O0250B	Influenza vaccine - Date influenza vaccine received	RIAV	RIAV	RIAV	RIAV	—	N	Y
O0250C	Influenza vaccine - if influenza vaccine not received, state reason	R	R	R	R	Part of numerator calculation for Influenza vaccination measure	N	Y
Z0400A	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	Y
Z0400B	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400C	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400D	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400E	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400F	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400G	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400H	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400I	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400J	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400K	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0400L	Attestation signature, title, sections, date	N/A	N/A	N/A	N/A	—	N	N
Z0500A	Attestation signature of person verifying completion	N/A	N/A	N/A	N/A	—	N	N
Z0500B	LTCH CARE Data Set Completion Date	R	R	R	R	System cannot accept record without response	N	Y
	Key:
	R: Required	106	67	39	19
	RIAV: Required if information is available	91	57	32	27
	Total Required	197	124	71	46
	N/A: Not Applicable	42	115	168	193
	Required for Assessment Completion Time	87	65	37	18
	RIAV for Assessment Completion Time	22	19	11	9
	Total Required for Assessment Completion Time	109	84	48	27

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