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Federal forms, ICRs, and supporting documents

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 202304-0938-012 · OMB 0938-1140.

Documents and Forms
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Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
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Information Collection (IC) Details

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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)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 413.343 42 CFR 483.20 42 CFR 413.337 42 CFR 424.32

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10387 Nursing Home PPS (NP) Item Set Draft MDS3.0 NP Item Set v1.18.11 Oct2023.pdf Yes Yes Fillable Printable
Form and Instruction CMS-10387 Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Cover Only) Cover Page MDS RAI Manual v1.18.11.docx https://www.cms.gov/files/document/draftmds-30-rai-manual-v11811october2023.pdf-0 Yes Yes Fillable Fileable
Form and Instruction CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set Draft MDS3.0 NPE Item Set v1.18.11 Oct2023.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10387 Interim Payment Assessment (IPA) Item Set Draft MDS3.0 IPA Item Set v1.18.11 Oct2023.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10387 Swing Bed Discharge (SD) Item Set Draft MDS3.0 SD Item Set v1.18.11 Oct2023.pdf Yes Yes Fillable Fileable
Form and Instruction CMS-10387 Swing Bed PPS (SP) Item Set Draft MDS3.0 SP Item Set v1.18.11 Oct2023.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

15,472 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,371,993 0 -1,533,049 0 0 4,905,042
Annual IC Time Burden (Hours) 2,866,194 0 -1,303,092 0 0 4,169,286
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Crosswalk Draft MDS3.0_Item Set Change History_v1.18.11 Oct2023.pdf 04/19/2023
NP Item set v1.18.11 new items Draft MDS3.0 NP Item Set v1.18.11 Oct2023+ new items highlighted.docx 04/19/2023
NPE Item Set v1.18.11 new items Draft MDS3.0 NPE Item Set v1.18.11 Oct2023+ new items highlighted.docx 04/19/2023
IPA Item Set v1.18.11 new items Draft MDS3.0 IPA Item Set v1.18.11 Oct2023+ new items highlighted.docx 04/19/2023
SD Item Set v1.18.11 new items Draft MDS3.0 SD Item Set v1.18.11 Oct2023 + new items highlighted.docx 04/19/2023
SP Item Set v1.18.11 new item Draft MDS3.0 SP Item Set v1.18.11 Oct2023 + new items higlighted.docx 04/19/2023
NP item set v1.18.11 removed items MDS3.0_NP_PPS_v1.17.2+ removed items redlined.docx 04/19/2023
NPE item set v1.18.11 removed items MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.2 + removed items redlined.docx 04/19/2023
IPA item set v1.18.11 removed items MDS3.0_IPA_v1.17.2 + removed items redlined.docx 04/19/2023
SD item set v1.18.11 removed items MDS3.0_SD_Dschg_v1.17.2 + removed items redlined.docx 04/19/2023
SP item set v1.18.11 removed items MDS3.0_SP_PPS_v1.17.2 + removed items redlined.docx 04/19/2023
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.