(CMS-10279) Ambulatory Surgical Centers Conditions of Coverage

Forms and Documents

Document Name	Status
CMS-10279 12-2-2019 clean.docx Supporting Statement A	2019-12-03

IC Document Collections

IC ID	Document Title	Status
233417	Ambulatory Surgical Centers Conditions of Coverage 416.52(a)	Modified
189557	Ambulatory Surgical Centers Conditions of Coverage (416.50)(a)(3)	Unchanged
189556	Ambulatory Surgical Centers Conditions of Coverage (416.50)(a)(1)	Modified
189555	Ambulatory Surgical Centers Conditions of Coverage (416.43)	Unchanged
189554	Ambulatory Surgical Centers Conditions of Coverage (416.41)	Unchanged

ICR Details

OMB Control No: 0938-1071	ICR Reference No: 201911-0938-005
Status: Active	Previous ICR Reference No: 201810-0938-002
Agency/Subagency: HHS/CMS	Agency Tracking No: 20480
Title: (CMS-10279) Ambulatory Surgical Centers Conditions of Coverage
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: 12/03/2019
	Date Received in OIRA: 11/15/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	08/31/2020
Responses	22,285	0	22,000
Time Burden (Hours)	262,946	0	214,500
Cost Burden (Dollars)	0	0	0

---

Abstract: This information collection package is a request for extension of information collection requirements. With this submission, we have updated the current number of Ambulatory Surgical Centers and wages/salary figures. The information collection requirements, as discussed in the supporting statement, are needed to implement the Medicare and Medicaid Conditions for Coverage for 5557 Ambulatory Surgical Centers.

---

Authorizing Statute(s): PL: Pub.L. 96 - 499 934 Name of Law: Outpatient Surgery
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AT23	Final or interim final rulemaking	84 FR 51732	09/30/2019

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Ambulatory Surgical Centers Conditions of Coverage (416.41)
Ambulatory Surgical Centers Conditions of Coverage (416.43)
Ambulatory Surgical Centers Conditions of Coverage (416.50)(a)(1)
Ambulatory Surgical Centers Conditions of Coverage (416.50)(a)(3)
Ambulatory Surgical Centers Conditions of Coverage 416.52(a)

---

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	22,285	22,000	0	285	0	0
Annual Time Burden (Hours)	262,946	214,500	0	48,446	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: We have adjusted the burden estimates to reflect that the previously approved one-time burden at §416.50(a)(1) for all ASCs to develop a patient rights form will only be incurred by an estimated 57 new ASCs each year in the future. In addition, we have annualized the new one-time burden associated with 84 FR 51732 at §416.52(a) over the 3-year approval period. These changes result in a decrease of burden from 377,876 hours to 262,946 hours compared to what was proposed, or a decrease of 48,446 compared to the previous approved package (ICR Reference Number: 201704-0938-009). Refer to Table 4 for details.

---

Annual Cost to Federal Government: $0

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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

---

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: 11/15/2019

---