CMS-10409 LCDS version 4.00 Unplanned Discharge

Patient

Identifier

Date

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1163 (Expiration Date: XX/XX/XXXX). The time required to complete this information collection is estimated
to average 14 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please
do not send applications, claims, payments, medical records, or any documents containing sensitive information to
the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
collection burden approved under the associated OMB control number listed on this form will not be reviewed,
forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please
contact Lorraine Wickiser at Lorraine.Wickiser@cms.hhs.gov.

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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Patient

Identifier

Date

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

Day

Year

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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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Patient

Identifier

Section A

Date

Administrative Information

Patient Demographic Information .
A0500. Legal Name of Patient.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_

_
Month

Day

Year

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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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Patient

Identifier

Section A

Date

Administrative Information

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 payer source
X. Unknown
Y. Other .

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
Intellectually Disabled/Developmentally Disabled (ID/DD) facility
Hospice
Discharged Against Medical Advice
Other

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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Patient

Section C

Identifier

Date

Cognitive Patterns

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

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

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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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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 M0210, Unhealed Pressure Ulcers/Injuries
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

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?
Skip to N2005, Medication Intervention
0. No
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

Enter Number

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

Enter Number

Skip to M0300D, Stage 4.

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

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

Enter Number

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

Skip to M0300G,

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

Enter Number

Skip to N2005, Medication Intervention

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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

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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

Final LTCH CARE Data Set Version 4.00, Unplanned Discharge - Effective July 1, 2018

Day

Year

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