Information Collection

Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)

IC 197759 under ICR 201909-0938-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10387 Nursing Home PPS (NP) Item Set Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction
Form CMS-10387 Nursing Home and Swing Bed OMRA (NO/SO) Item Set Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction
Form CMS-10387 Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Cover Only) Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction
Form CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction
Form CMS-10387 Interim Payment Assessment (IPA) Item Set Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction
Form CMS-10387 Final SNF QRP New and Modified Items Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)	Form and Instruction
CMS-10387 Nursing Home PPS (NP) Item Set MDS3.0_NP_PPS_v1.17.1.pdf	Form and Instruction
CMS-10387 Nursing Home and Swing Bed OMRA (NO/SO) Item Set MDS3.0_NO_SO_OMRA-Other_v1.16.1.pdf	Form and Instruction
CMS-10387 Long-Term Care Facility Resident Assessment Instrument ( MDS RAI Manual v1.16 PRA cover page.pdf downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf	Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.1.pdf	Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set MDS3.0_IPA_v1.17.1.pdf	Form and Instruction
CMS-10387 Final SNF QRP New and Modified Items Final-SNF-QRP-Item-Mockups-Effective-October-1-2020.pdf www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Final-SNF-QRP-	Form and Instruction
Crosswalk for Changes to MDS 3.0_PRA_Final_clean 08272019.docx Crosswalk	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Skilled Nursing Facility (SNF) Minimum Data Set (MDS) 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) Item Sets (NP, NO/SO, NS, NOD, NSD)

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 424.32 42 CFR 413.343 42 CFR 483.20 42 CFR 413.337

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10387		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10387	https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Final-SNF-QRP-Item-Mockups-Effective-October-1-2020.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,471

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,905,042	4,905,042
Annual IC Time Burden (Hours)	4,169,286	4,169,286
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk		09/25/2019

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

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