Form CMS-10409 Proposed LTCH QRP New and Modified Items

Proposed LTCH QRP New and Modified Items
Effective Date: October 1, 2020
ADMISSION
Section A

Administrative Information

A1005. Ethnicity
Are you Hispanic, Latino/a, or Spanish origin?
Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E. Yes, Another Hispanic, Latino, or Spanish origin
X. Patient unable to respond
A1010. Race
What is your race?
Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E. Chinese
F. Filipino
G. Japanese
H. Korean
I. Vietnamese
J. Other Asian
K. Native Hawaiian
L. Guamanian or Chamorro
M. Samoan
N. Other Pacific Islander
X. Patient unable to respond
A1110. Language
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I
need
C. No
D. Patient unable to respond
A1805. Admitted From
Enter Code
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed

Section B

Hearing, Speech, and Vision

B0200. Hearing
Enter Code
Ability to hear (with hearing aid or hearing appliances if normally used)
0. Adequate – no difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty – difficulty in some environments (e.g., when person speaks softly or
setting is noisy)
2. Moderate difficulty – speaker has to increase volume and speak distinctly
3. Highly impaired – absence of useful hearing

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

B1000. Vision
Enter Code
Ability to see in adequate light (with glasses or other visual appliances)
0. Adequate – sees fine detail, such as regular print in newspapers/books
1. Impaired – sees large print, but not regular print in newspapers/books
2. Moderately impaired – limited vision; not able to see newspaper headlines but can identify
objects
3. Highly impaired – object identification in question, but eyes appear to follow objects
4. Severely impaired – no vision or sees only light, colors or shapes; eyes do not appear to
follow objects
B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0. No (patient is rarely/never understood)  Skip to XXXX
1. Yes  Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code
Ask patient: “I am going to say three words for you to remember. Please repeat the words after I
have said all three. The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues (“sock, something to wear; blue, a
color; bed, a piece of furniture”). You may repeat the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Enter Code
Ask patient: “Please tell me what year it is right now.”
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Ask patient: “What month are we in right now?”
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Enter Code
Ask patient: “What day of the week is today?”
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct
C0400. Recall
Enter Code
Ask patient: “Let's go back to an earlier question. What were those three words that I asked you
to repeat?” If unable to remember a word, give cue (something to wear; a color; a piece of
furniture) for that word.
A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
Enter Code
B. Able to recall “blue”
0. No - could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
Enter Code
C. Able to recall “bed”
0. No - could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required
C0500. BIMS Summary Score
Enter Code

Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
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
Enter Code in Boxes
Coding:
B. Inattention - Did the patient have difficulty focusing attention, for
0. Behavior not
example being easily distractible or having difficulty keeping track of
present
what was being said?
1. Behavior
C. Disorganized thinking - Was the patient's thinking disorganized or
continuously
incoherent (rambling or irrelevant conversation, unclear or illogical flow
present, does
of ideas, or unpredictable switching from subject to subject)?

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

not fluctuate
2. Behavior present,
fluctuates (comes
and goes, changes
in severity)

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.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section D

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
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
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence
Frequency
9. No response (leave column 2
2. 7-11 days (half or more of the
blank)
days)
Enter Scores in Boxes
3. 12-14 days (nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the
PHQ interview and SKIP to next section.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let yourself or
your family down
G. Trouble concentrating on things, such as reading the newspaper or
watching television
H. Moving or speaking so slowly that other people could have noticed. Or the
opposite – being so fidgety or restless that you have been moving around a
lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in some
way
D0160. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be
between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required
items)

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period)
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

F. Toilet transfer: The ability to get on and off a toilet or commode. If admission
performance is coded 07, 09, 10, or 88  Skip to GG0170I, Walk 10 feet
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room,
corridor, or similar space. If admission performance is coded 07, 09, 10, or 88
 Skip to GG0170M, 1 step (curb)
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

G. Car transfer: The ability to transfer in and out of a car or van on the passenger
side. Does not include the ability to open/close door or fasten seat belt.
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or
sloping surfaces (indoor or outdoor), such as turf or gravel.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

M. 1 step (curb): The ability to go up and down a curb and/or up and down one
step. If admission performance is coded 07, 09, 10, or 88  Skip to GG0170P,
Picking up object
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

N. 4 steps: The ability to go up and down four steps with or without a rail. If
admission performance is coded 07, 09, 10, or 88  Skip to GG0170P, Picking
up object
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
1.
2.
Admission Discharge
Performance
Goal
Enter Codes in Boxes

P. Picking up object: The ability to bend/stoop from a standing position to pick
up a small object, such as a spoon, from the floor.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section J

Health Conditions

J0510. Pain Effect on Sleep
Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?”
0. Does not apply – I have not had any pain or hurting in the past 5 days  Skip to XXXX
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply on admission.
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (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

Section N

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications in the
following drug classes
2. Indication noted
If Column 1 is checked, check if there is an indication noted
for all medications in the drug class

1. Is taking

2. Indication noted

Check all that apply
↓

Check all that apply
↓

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
↓ Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy Care
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above
O0150. Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar Trial (TCT) or Continuous Positive
Airway Pressure (CPAP) Breathing Trial) by Day 2 of the LTCH Stay (Note: Day 2 = Date of Admission to the
LTCH (Day 1) + 1 calendar day)
Enter Code A. Invasive Mechanical Ventilation Support upon Admission to the LTCH
0. No, not on invasive mechanical ventilation support upon admission  Skip to Z0400,
Signature of Persons Completing the Assessment
1. Yes, on invasive mechanical ventilation support upon admission  Continue to O0150A2,
Ventilator Weaning Status
Enter Code
A2. Ventilator Weaning Status
0. No, determined to be non-weaning upon admission  Skip to Z0400, Signature of
Persons Completing the Assessment
1. Yes, determined to be weaning upon admission  Continue to O0150B, Assessed for
readiness for SBT by day 2 of LTCH stay
Enter Code B. Assessed for readiness for SBT by day 2 of the LTCH stay
0. No  Skip to Z0400, Signature of Persons Completing the Assessment
1. Yes  Continue to O0150C, Deemed medically ready for SBT by day 2 of the LTCH stay
Enter Code C. Deemed medically ready for SBT by day 2 of the LTCH stay
0. No  Continue to O0150D, 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?
1. Yes  Continue to O0150E, If the patient was deemed medically ready for SBT, was SBT
performed by day 2 of the LTCH stay?
Enter Code D. 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?
0. No  Skip to Z0400, Signature of Persons Completing the Assessment
1. Yes  Skip to Z0400, Signature of Persons Completing the Assessment
Enter Code E. If the patient was deemed medically ready for SBT, was SBT performed by day 2 of the LTCH
stay?
0. No
1. Yes

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

PLANNED DISCHARGE
Section A

Administrative Information

A1110. Language
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

A1250. Transportation
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things
needed for daily living?
Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I
need
C. No
D. Patient unable respond
A2105. Discharge Location
Enter Code
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the patient’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

A2122. Provision of Current Reconciled Medication List to Patient at Discharge
At the time of discharge, did your facility provide the patient’s current reconciled medication list to the
patient, family and/or caregiver?
Enter Code
0. No – Current reconciled medication list not provided to the patient, family and/or
caregiver
1. Yes – Current reconciled medication list provided to the patient, family and/or caregiver
A2123. Route of Current Reconciled Medication List Transmission
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
and/or patient/family/caregiver.
1.
2.
To subsequent
To patient/family/
Route of Transmission
provider
caregiver
↓ Check all that apply ↓

A.
B.
C.
D.
E.

Electronic Health Record
Health Information Exchange Organization
Verbal (e.g., in-person, telephone, video conferencing)
Paper-based (e.g., fax, copies, printouts)
Other Methods (e.g., texting, email, CDs)

Section B



















Hearing, Speech, and Vision

B1300. Health Literacy
How often do you need to have someone help you when you read instructions, pamphlets, or other written
material from your doctor or pharmacy?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all patients.
Enter Code

0. No (patient is rarely/never understood)  Skip to XXXX
1. Yes  Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code
Ask patient: “I am going to say three words for you to remember. Please repeat the words after I
have said all three. The words are: sock, blue and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient's first attempt, repeat the words using cues (“sock, something to wear; blue, a
color; bed, a piece of furniture”). You may repeat the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Enter Code
Ask patient: “Please tell me what year it is right now.”
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Enter Code
Ask patient: “What month are we in right now?”
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Enter Code
Ask patient: “What day of the week is today?”
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct
C0400. Recall
Enter Code
Ask patient: “Let's go back to an earlier question. What were those three words that I asked you
to repeat?” If unable to remember a word, give cue (something to wear; a color; a piece of
furniture) for that word.
A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
Enter Code
B. Able to recall “blue”
0. No - could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

C. Able to recall “bed”
0. No - could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required
C0500. BIMS Summary Score
Enter Code

Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.
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
Enter Code in Boxes
Coding:
B. Inattention - Did the patient have difficulty focusing attention, for
0. Behavior not
example being easily distractible or having difficulty keeping track of what
present
was being said?
1. Behavior
C. Disorganized thinking - Was the patient's thinking disorganized or
continuously
incoherent (rambling or irrelevant conversation, unclear or illogical flow of
present, does
ideas, or unpredictable switching from subject to subject)?
not fluctuate
D. Altered level of consciousness - Did the patient have altered level of
2. Behavior present,
consciousness as indicated by any of the following criteria?
fluctuates (comes
■ vigilant - startled easily to any sound or touch
and goes, changes
■ lethargic - repeatedly dozed off when being asked questions, but
in severity)
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.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section D

Mood

D0150. Patient Mood Interview (PHQ-2 to 9)
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
1.
2.
0. No (enter 0 in column 2)
0. Never or 1 day
Symptom
Symptom
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Presence
Frequency
9. No response (leave column 2
2. 7-11 days (half or more of the
blank)
days)
Enter Scores in Boxes
3. 12-14 days (nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the
PHQ interview and SKIP to next section.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let yourself or
your family down
G. Trouble concentrating on things, such as reading the newspaper or
watching television
H. Moving or speaking so slowly that other people could have noticed. Or the
opposite – being so fidgety or restless that you have been moving around a
lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in some
way
D0160. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be
between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required
items)

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
9. Patient unable to respond

Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period)
3.
Discharge
Performance
Enter Codes in Boxes

F. Toilet transfer: The ability to get on and off a toilet or commode. If discharge performance
is coded 07, 09, 10, or 88  Skip to GG0170I, Walk 10 feet
3.
Discharge
Performance
Enter Codes in Boxes

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 GG0170M, 1
step (curb)
3.
Discharge
Performance
Enter Codes in Boxes

G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does
not include the ability to open/close door or fasten seat belt.
3.
Discharge
Performance
Enter Codes in Boxes

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping
surfaces (indoor or outdoor), such as turf or gravel.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

3.
Discharge
Performance
Enter Codes in Boxes

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. If
discharge performance is coded 07, 09, 10, or 88  Skip to GG0170P, Picking up object
3.
Discharge
Performance
Enter Codes in Boxes

N. 4 steps: The ability to go up and down four steps with or without a rail. If admission
performance is coded 07, 09, 10, or 88  Skip to GG0170P, Picking up object
3.
Discharge
Performance
Enter Codes in Boxes

O. 12 steps: The ability to go up and down 12 steps with or without a rail.
3.
Discharge
Performance
Enter Codes in Boxes

P. Picking up object: The ability to bend/stoop from a standing position to pick up a small
object, such as a spoon, from the floor.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section J

Health Conditions

J0510. Pain Effect on Sleep
Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?”
0. Does not apply – I have not had any pain or hurting in the past 5 days  Skip to XXXX
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?”
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost Constantly
9. Unable to answer

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
1. Last 7 days
Check all of the nutritional approaches that were received in
the last 7 days
2. At discharge
Check all of the nutritional approaches that were being
received at discharge

1. Last 7 days

2. At discharge

Check all that apply
↓

Check all that apply
↓

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (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

Section N

Medications

N0420. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications in the
following drug classes
2. Indication noted
If Column 1 is checked, check if there is an indication
noted for all medications in the drug class

1. Is taking

2. Indication noted

Check all that apply
↓

Check all that apply
↓

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
↓ Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy Care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above
O0200. Ventilator Liberation Rate (Note: 2 calendar days prior to discharge = 2 calendar days + day of
discharge)
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. Not applicable (code only if the patient was not on invasive mechanical ventilator
support upon admission [O0150A = 0] or the patient was determined to be nonweaning upon admission [O0150A2 = 0])

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

UNPLANNED DISCHARGE
Section A

Administrative Information

A1990. Patient Discharged Against Medical Advice?
Enter Code

0. No
1. Yes

A2105. Discharge Location
Enter Code
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements)
02. Nursing home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not Listed
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
At the time of discharge to another provider, did your facility provide the patient’s current reconciled
medication list to the subsequent provider?
Enter Code

0. No – Current reconciled medication list not provided to the subsequent provider
1. Yes – Current reconciled medication list provided to the subsequent provider

A2122. Provision of Current Reconciled Medication List to Patient at Discharge
At the time of discharge, did your facility provide the patient’s current reconciled medication list to the
patient, family and/or caregiver?
Enter Code
0. No – Current reconciled medication list not provided to the patient, family and/or
caregiver
1. Yes – Current reconciled medication list provided to the patient, family and/or caregiver

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

A2123. Route of Current Reconciled Medication List Transmission
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
and/or patient/family/caregiver.
1.
2.
To subsequent
To patient/family/
Route of Transmission
provider
caregiver
↓ Check all that apply ↓

A.
B.
C.
D.
E.

Electronic Health Record
Health Information Exchange Organization
Verbal (e.g., in-person, telephone, video conferencing)
Paper-based (e.g., fax, copies, printouts)
Other Methods (e.g., texting, email, CDs)

Section C



















Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after reviewing medical record.
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
Enter Code in Boxes
Coding:
B. Inattention - Did the patient have difficulty focusing attention, for
0. Behavior not
example being easily distractible or having difficulty keeping track of what
present
was being said?
1. Behavior
C. Disorganized thinking - Was the patient's thinking disorganized or
continuously
incoherent (rambling or irrelevant conversation, unclear or illogical flow
present, does
of ideas, or unpredictable switching from subject to subject)?
not fluctuate
D. Altered level of consciousness - Did the patient have altered level of
2. Behavior present,
consciousness as indicated by any of the following criteria?
fluctuates (comes
■ vigilant - startled easily to any sound or touch
and goes, changes
■ lethargic - repeatedly dozed off when being asked questions, but
in severity)
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.

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
1. Last 7 days
1. Last 7 days
Check all of the nutritional approaches that were received in the
last 7 days
Check all that apply
2. At discharge
↓
Check all of the nutritional approaches that were being received
at discharge

2. At discharge
Check all that apply
↓

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (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

Section N

Medications

N0420. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications in the
following drug classes
2. Indication noted
If Column 1 is checked, check if there is an indication noted
for all medications in the drug class

1. Is taking

2. Indication noted

Check all that apply
↓

Check all that apply
↓

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
↓ Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy Care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020

O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above
O0200. Ventilator Liberation Rate (Note: 2 calendar days prior to discharge = 2 calendar days + day of
discharge)
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. Not applicable (code only if the patient was not on invasive mechanical ventilator
support upon admission [O0150A = 0] or the patient was determined to be non-weaning
upon admission [O0150A2 = 0])

LTCH QRP New and Modified Item Mockups as delineated in the FY 2020 IPPS/LTCH PPS Proposed Rule, Proposed Effective Date:
October 1, 2020