CMS-360 crosswalk

Revisions to CMS-360 Form –

Comprehensive Outpatient Rehabilitation Facility Report

Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
1	Section 1 Row 1, Column 1	Change title of data item #1	Change title of data item #1 from: “Name of Facility” to “Facility Name”	The new title is more succinct.
1	Section 1, Row 1. Column 2	Add a new column to row #1 of section #1. 2. Add a title to this new data field.	1. Add a 2nd column to row 1 of section 1, and Add the following text to new data field: “Facility CCN”	We have moved the space for facility CCN number up to Row 1 to save space. Since this form will be a fillable .pdf form, the facility will be able to type in their responses. It will not require an entire row for the “Facility Name” because this field has been formatted to accommodate multiline text.
1	Section 1, Row 2, Column 1	Add a new title to column 1 of row 2 of section 1.	Change the current text in the data field from “Number” to “Facility Street Address”	In the current version of the CMS-360 form, it asks for the person completing the form to insert a “Number” in this data field. While we know that “Number” refers to the facility’s CCN number, many persons would not because this text is vague and non-descriptive. To solve this issue, we have moved the section for the facilities CCN number to row 1, column 2 and retitled it as “Facility CCN.” We placed this data field at row 1, column 2 because we believe that the logical order of the data to be required should be: 1. Facility Name and 2. Facility CCN…… We have changed the text in row 2, column 1 from “Number” to “Facility Street Address.” We made this change for several reasons. First, we believe that the facility address would be the next data point to be collected in the logical order of the data collected. Second. We have made this change to place each component of the facilities address into separate data fields. We believe that this is better for ease of data input and use of data that will be downloaded from the CMS-360 form
1	Section 1, Rows 2 & 3, Colum 2	Delete current title and replace it with a new tile for this data field	Change the text in this data field from: “Facility Address, Street, City, State, Zip Code” to “City”	In the current version of the CMS-360 form, it asks for the person completing the form to enter the entire address of the facility into this one data field. We have made this change to place each component of the facilities address into separate data fields. We believe that this is better for ease of data input and use of data that will be downloaded from the CMS-360 form.
1	Section 1, (New) Row 3, Column 1	Add a new row 3 to section 1 Add title text to column 1 of row 3	Add a new row 3 containing 3 columns to section 1. Add the following text to column 1 of row 3: “State” Add the following text to column 2 of row 3: “Zip Code” Add the following text to column 3 of row 3: “Telephone Number”	In the current version of the CMS-360 form, it asks for the person completing the form to enter the entire address of the facility into this one data field. We have added a third row to section 1 to allow for placement of each individual component of the facilities address into separate data fields. We believe that format provides easier data input and use of the data that will be downloaded from the CMS-360 form.
1	Section. Row 4 (row 3 in existing version of CMS-360 form), Column 1	Retitle the data field in column 1 of row 4. NOTE: Row 3 in the existing version of the form becomes row 4 in the new version of the form due to the addition of a new row 3.	Change the text in this data field from: “Survey Date” to “Survey Start Date”	In this data fiend on the existing version of the CMS-360 form, it asks for the “Survey date.” We believe that this title would be confusing to persons completing the form because they might not know whether to record the survey start date or end date. To solve this issue, we have modified the title of this data field to “Survey Start Date.” This is much more specific. We have also added a new data field in column 2 for the survey end date (see below).
1	Section. Row 4 (row 3 in existing version of CMS-360 form), Column 2	Retitle the data field in column 2 of row 4. NOTE: Row 3 in the existing version of the form becomes row 4 in the new version of the form due to the addition of a new row 3.	Change the text in this data field from: “Type of Survey” “Initial Resurvey” to “Survey End Date”	We have made this change so that the person completing this form can document both the survey start and end dates. Also, when referring to the survey date, for most purposes CMS uses the survey end data, so adding this data field is necessary. We have moved the data field for type of survey to a newly created data field in column 3 of row 4. (see below)
1	Section. Row 4 (row 3 in existing version of CMS-360 form), Column 3	Divide the rows 3 and 4 in the 3rd column into separate data fields. Add a title the new data field in column 3 of row 4. NOTE: Row 3 in the existing version of the form becomes row 4 in the new version of the form due to the addition of a new row 3.	Divide the rows 3 and 4 in the 3rd column into separate data fields. Add the following title to the new data field in column 3 of row 4: “Type of Survey Initial Recertification survey Complaint Other (specify)”	In the existing version of the CMS-360 form, rows 2 & 3 in column 3 are merged into one data field for “Facility Address” As explained above, in the revised version of the CMS-360 form, we have placed the individual components of the facility’s address into data field. Therefore, there was no longer a need for the 2 cells in rows 2 and 3 in column 3 to be merged. We separated this merges cell into 2 separate data cells to maximize the amount of data that could be collected in section 1. As stated above, we added “Telephone Number” to column 3 of row 3. We also moved the data field for “Type of Survey to the cell at column 3 in row 4.