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 IRF PAI Instrument	Form	Modified	Available
Form CMS-10036 IRF PAI Instrument	Form	Modified	Available
Form CMS-10036 IRF PAI Instrument	Form	Modified	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036_IRF-PAI_Revisions Crosswalk.docx	Supplementary Document	Uploaded 2011-06-01	Available
CMS-10036.CLEAN - Supporting Statement Part A(012612).docx	Supporting Statement A	Uploaded 2012-01-27	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	IRF PAI Instrument
187984	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Instruction	Modified
187984	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	Modified	IRF PAI Instrument
187983	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Instruction	Modified
187983	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Form	Modified	IRF PAI Instrument

ICR Details

OMB Control No: 0938-0842	ICR Reference No: 201106-0938-001
Status: Historical Active	Previous ICR Reference No: 200902-0938-004
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: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/28/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/01/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	36 Months From Approved	05/31/2012
Responses	486,550	0	396,660
Time Burden (Hours)	413,568	0	337,162
Cost Burden (Dollars)	0	0	0

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Abstract: The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) is an instrument for collecting standardized patient assessment data for 1) the objective assignment of Medicare beneficiaries to appropriate Case Mix Groups (CMGs); 2) the development of a system to monitor the effects of an inpatient rehabilitation facility prospective payment system on patient care and outcomes; 3) the determination of whether future adjustments to the CMGs are warranted; and 4) the development of an integrated system for post-acute care. The information provided on the IRF-PAI is used to establish reimbursement under the prospective payment system for inpatient rehabilitation facility services for the Medicare program.

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Authorizing Statute(s): PL: Pub.L. 105 - 1 4421 Name of Law: Prospective Payment for Inpatient Rehab Hospital Services
   US Code: 42 USC 1395ww(jX2)(d) Name of Law: Prospective Payment for Inpatient Rehab Services
   PL: Pub.L. 111 - 148 3004 Name of Law: Quality Reporting for Long-Term Care Hospitals, etc.
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3004 Name of Law: Quality Reporting for Long-Term Care Hospitals, etc.

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ28	Final or interim final rulemaking	76 FR 24214	04/29/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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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	IRF PAI Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	CMS-10036	IRF PAI Instrument
Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P (CMS-10036)	CMS-10036	IRF PAI Instrument

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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	486,550	396,660	89,890	0	0	0
Annual Time Burden (Hours)	413,568	337,162	76,406	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: $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]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 06/01/2011

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