Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI)

Forms and Documents

Document Name	Status
Form CMS-R-143 Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI) Form and Instruction	Modified
Form CMS-R-143 Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI) Form and Instruction	New
CMS-R-143.Supporting Statement (2006).doc Supporting Statement A	2006-09-07

IC Document Collections

IC ID	Document Title	Status
8178	Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI) Form and Instruction	Modified
45685	Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI) Form and Instruction	New

ICR Details

OMB Control No: 0938-0575	ICR Reference No: 200610-0938-007
Status: Historical Active	Previous ICR Reference No: 200306-0938-003
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/22/2006
	Date Received in OIRA: 10/16/2006
Terms of Clearance: Approved consistent with the modified version uploaded in ROCIS.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2009	36 Months From Approved	11/30/2006
Responses	50	0	50
Time Burden (Hours)	150	0	150
Cost Burden (Dollars)	0	0	0

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Abstract: Survey of medical liability insurers for use in computing the malpractice component of the geographic practice cost index as set forth in the Omnibus Budget Reconciliation Act of 1989, H.R. 3299.

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Authorizing Statute(s): US Code: 42 USC 1395w-4(c) Name of Law: Determination of relative values for physicians' services
   US Code: 42 USC 1395w-4(e) Name of Law: Geographic adjustment factors
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 33460	06/09/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 52079	09/01/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI)	CMS-R-143	R-143survey
Medicare Physician Fee Schedule Geographic Practice Expense Index (GPCI)	CMS-R-143	CMS-R-143 Survey

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	50	50	0	0	0	0
Annual Time Burden (Hours)	150	150	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $268

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/26/2006

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