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Kentucky MAP-4092: PASRR Exempted Hospital Discharge

Kentucky's pre-admission screening and resident review (PASRR) process uses MAP-4092 when a hospital patient goes to a nursing facility for continued care of the same condition and the stay is expected to last less than 30 days. The attending physician certifies the short stay, which exempts the admission from a Level II evaluation. The original remains in the chart.

Who completes it

The attending physician signs and prints their name to certify the exempted hospital discharge. A second signer certifies that it is the signature of the treating or discharging physician where the applicant is located; the form also records the hospital, receiving nursing facility and its Medicaid provider number.

Submitting and payment

How to submit it
The original stays in the chart, and the nursing facility keeps the form with the MAP 409 Level I screen; the form records the date it was transmitted.
Who pays
The form sets no fee for the physician; it is a PASRR screening document rather than a billing form.

Good to know

  • All three conditions must apply: admission from an acute care setting, continued nursing facility care for the hospital condition, and an expected stay of less than 30 days.
  • If the resident later needs more than 30 days, a Level II PASRR must be completed within 40 calendar days of admission.
  • The nursing facility refers the resident for Level II before the 30 days end by sending MAP 409 with MAP 4092; the CMHC then has 9 days to evaluate.
  • The form notes whether the Level I screen triggered mental illness or an intellectual disability or related condition. The current version is dated December 2025.

Get the official form

Download the current version from the source each time; forms change without notice.

Exempted Hospital Discharge Physician Certification of Need for Nursing Facility Services

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What is an exempted hospital discharge in Kentucky PASRR?

An admission to a nursing facility directly from an acute care setting, for continued care of the condition treated in the hospital, that is expected to last less than 30 days. When all three apply and the attending physician signs MAP-4092, the Level II PASRR is not required at admission.

What happens if the stay goes beyond 30 days?

If the resident is later found to need more than 30 days of nursing facility care, a Level II PASRR must be completed within 40 calendar days of admission. The facility refers the resident before the exempt 30 days end by submitting the MAP 409 with the MAP 4092.