Information Collection

MDS 3.0 PPS Item Sets Preparation, Encoding, and Transmission Time

IC 197759 under ICR 201305-0938-024 · OMB 0938-1140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1140 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-R-250 MDS 3.0 PPS Item Sets Preparation, Encoding, and Transmission Time Form and Instruction
CMS-R-250 Nursing Home PPS (NP) Item Set MDS3 0_NP_PPS_v1 11 1.pdf Form and Instruction
CMS-R-250 Nursing Home OMRA-Start of Therapy and Discharge (NSD) I MDS3 0_NSD_OMRA-SOT-Dschg_v1 11 1.pdf Form and Instruction
CMS-R-250 Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) MDS3 0_NS_SS_OMRA-SOT_v1 11 1.pdf Form and Instruction
CMS-R-250 Nursing Home OMRA-Discharge (NOD) Item Set. MDS3 0_NOD_OMRA-Other-Dschg_v1 11 1.pdf Form and Instruction
CMS-R-250 Nursing Home and Swing Bed OMRA (NO/SO) Item Set MDS3 0_NO_SO_OMRA-Other_v1 11 1.pdf Form and Instruction
Crosswalk for Change to MDS 3_PRA_FY2014.docx Crosswalk - Changes to MDS 3.0 Item Sets IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MDS 3.0 PPS Item Sets Preparation, Encoding, and Transmission Time	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.343 42 CFR 413.337 42 CFR 424.32 42 CFR 483.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-250	Nursing Home PPS (NP) Item Set	MDS3 0_NP_PPS_v1 11 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-250	Nursing Home OMRA-Start of Therapy and Discharge (NSD) Item Set	MDS3 0_NSD_OMRA-SOT-Dschg_v1 11 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-250	Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) Item Set	MDS3 0_NS_SS_OMRA-SOT_v1 11 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-250	Nursing Home OMRA-Discharge (NOD) Item Set.	MDS3 0_NOD_OMRA-Other-Dschg_v1 11 1.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-250	Nursing Home and Swing Bed OMRA (NO/SO) Item Set	MDS3 0_NO_SO_OMRA-Other_v1 11 1.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Long Term Care Minimum Data Set	FR Citation: 63 FR 28396

Number of Respondents: 15,376	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,396,416	5,510,814	1,110	884,492
Annual IC Time Burden (Hours)	6,609,630	5,681,004	14,742	913,884
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk - Changes to MDS 3.0 Item Sets	Crosswalk for Change to MDS 3_PRA_FY2014.docx	05/29/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.