Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment Instrument	Form	Modified	Available
Form CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment Instrument	Form	New	Available
Form CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment Instrument	Form	New	Available
AdditonalInformationIRFPAIPRA08.doc	Supplementary Document	Uploaded 2009-01-22	Available
IRDPAICMS-10036 Supporting Statement.doc	Supporting Statement A	Uploaded 2009-03-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8648	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	Instruction	Modified
8648	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	Form	Modified	Inpatient Rehabilitation Facility - Patient Assessment Instrument
187984	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Instruction	New
187984	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	New	Inpatient Rehabilitation Facility - Patient Assessment Instrument
187983	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Instruction	New
187983	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	New	Inpatient Rehabilitation Facility - Patient Assessment Instrument

ICR Details

OMB Control No: 0938-0842	ICR Reference No: 200902-0938-004
Status: Historical Active	Previous ICR Reference No: 200512-0938-008
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities
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: 05/29/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/06/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2012	36 Months From Approved	05/31/2009
Responses	396,660	0	390,000
Time Burden (Hours)	337,162	0	421,939
Cost Burden (Dollars)	0	0	0

---

Abstract: We are requesting an extension of the existing approval for the assessment instrument that inpatient rehabilitation hospitals and inpatient rehabilitation units of a hospital (herein referred to as IRFs) are required to submit in the manner necessary to administer the payment rate methodology under the IRF PPS described in 42 CFR 412 Subpart P. The burden associated with this requirement is the staff time required to complete, encode and transmit the data from the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI).

---

Authorizing Statute(s): US Code: 42 USC 1395ww(jX2)(d) Name of Law: Prospective Payment for Inpatient Rehab Services
   PL: Pub.L. 105 - 1 4421 Name of Law: Prospective Payment for Inpatient Rehab Hospital Services
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AJ55	Final or interim final rulemaking	66 FR 41324	08/07/2001

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 63479	10/24/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 2078	01/14/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	CMS-10036	Inpatient Rehabilitation Facility - Patient Assessment Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	CMS-10036	Inpatient Rehabilitation Facility - Patient Assessment Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	CMS-10036	Inpatient Rehabilitation Facility - Patient Assessment Instrument

---

ICR Summary of Burden

table that charts list 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	396,660	390,000	0	0	6,660	0
Annual Time Burden (Hours)	337,162	421,939	0	0	-84,777	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: Total responses increased due to a more accurate estimate based upon actual data, not available at the time of the original estimate. Total burnden declined due to a reduction in the number of IRF admissions since fiscal year 2004.

---

Annual Cost to Federal Government: $2,000,000

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)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 02/06/2009

---