Information Collection

Recognition of payment for new technology services for ambulatory payment classification (APC) groups under the Outpatient Prospective Payment System (CMS- 10054)

IC 8676 under ICR 202407-0938-015 · OMB 0938-0860.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10054 Recognition of payment for new technology services for ambulatory payment classification (APC) groups under the Outpatient Prospective Payment System (CMS- 10054)	Form
CMS-10054 Process and Information Required for a New Technology Am CMS 10054 Form.pdf	Form
CMS-10054 Process and Information Required for a New Technology Am CMS 10054 Form.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Recognition of payment for new technology services for ambulatory payment classification (APC) groups under the Outpatient Prospective Payment System (CMS- 10054)

Agency IC Tracking Number:

CM-FFS

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 419

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10054	Process and Information Required for a New Technology Ambulatory Payment Classification (APC) Assignment Under the Hospital Outpatient Prospective Payment System (OPPS)	CMS 10054 Form.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: 28

Number of Respondents for Small Entity: 17

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	28	18	10
Annual IC Time Burden (Hours)	400	240	160
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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