(CMS-437) Psychiatric Unit Criteria Work Sheet and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-437 (437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations Form and Instruction	Modified
CMS-437 Supporting Statement A . 03.26.21.docx Supporting Statement A	2021-06-01

IC Document Collections

IC ID	Document Title	Status
7996	(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0358	ICR Reference No: 202106-0938-002
Status: Received in OIRA	Previous ICR Reference No: 201712-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-437) Psychiatric Unit Criteria Work Sheet and Supporting Regulations
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/01/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2021
Responses	1,598	1,616
Time Burden (Hours)	1,732	1,212
Cost Burden (Dollars)	0	0

---

Abstract: The psychiatric unit criteria work sheets are necessary to verify, on an annual basis, that these units meet the requirements to be excluded from payment under the Medicare Inpatient Prospective Payment System (IPPS) for the purpose of receiving payment under the Inpatient Psychiatric Prospective Payment System (IPF PPS).

---

Authorizing Statute(s): US Code: 42 USC 412 Name of Law: 25-27
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 14926	03/19/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 29264	06/01/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations	CMS-437	Psychiatric Unit Criteria Worksheet

---

ICR Summary of Burden

	Total Request	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	1,598	1,616	0	0	-18	0
Annual Time Burden (Hours)	1,732	1,212	0	0	520	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: The total annual burden hours have increase by 520 hours and the total annual cost burden has increased by $39,286. This increase is due to two factors. First we updated the burden calculations to include the time and cost burden required for a medical secretary to process the CMS-437 form after it has been completed. See section 12(b) for a list of the tasks that would be performed by the medical secretary. This time and cost burden was not included in the previous PRA package, but is a necessary part of the completion of the CMS-437

---

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? No

---

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: 06/01/2021

---