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 202509-0938-001 · OMB 0938-1140.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10387 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)	Form and Instruction
Form CMS-10387 Nursing Home PPS (NP) Item Set 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)	Form and Instruction
Form CMS-10387 Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Cover Only) 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)	Form and Instruction
Form CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set 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)	Form and Instruction
Form CMS-10387 Interim Payment Assessment (IPA) Item Set 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)	Form and Instruction
Form CMS-10387 Swing Bed Discharge (SD) Item Set 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)	Form and Instruction
Form CMS-10387 Swing Bed PPS (SP) Item Set 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)	Form and Instruction
CMS-10387 Nursing Home PPS (NP) Item Set CMS-10387 - Nursing Home PPS (NP) Item Set.pdf	Form and Instruction
CMS-10387 Nursing Home PPS (NP) Item Set CMS-10387 - Nursing Home PPS (NP) Item Set.pdf	Form and Instruction
CMS-10387 Long-Term Care Facility Resident Assessment Instrument ( Draft_MDS-3.0-RAI-Manual-v1.19.1_October_2024.pdf www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual	Form and Instruction
CMS-10387 Long-Term Care Facility Resident Assessment Instrument ( Draft_MDS-3.0-RAI-Manual-v1.19.1_October_2024.pdf www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual	Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set CMS-10387 - Nursing Home Part A PPS Discharge (NPE) Item-Set.pdf	Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set CMS-10387 - Nursing Home Part A PPS Discharge (NPE) Item-Set.pdf	Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set CMS-10387 - Interim Payment Assessment (IPA) -Item-Set.pdf	Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set CMS-10387 - Interim Payment Assessment (IPA) -Item-Set.pdf	Form and Instruction
CMS-10387 Swing Bed Discharge (SD) Item Set CMS-10387 - Swing Bed Discharge (SD) Item Set.pdf	Form and Instruction
CMS-10387 Swing Bed Discharge (SD) Item Set CMS-10387 - Swing Bed Discharge (SD) Item Set.pdf	Form and Instruction
CMS-10387 Swing Bed PPS (SP) Item Set CMS-10387 - Swing Bed PPS SP Item Set.pdf	Form and Instruction
CMS-10387 Swing Bed PPS (SP) Item Set CMS-10387 - Swing Bed PPS SP Item Set.pdf	Form and Instruction
CMS-10387 - Crosswalk of Changes - MDS 3.0 Item Set.pdf Crosswalk of Changes	IC Document
CMS-10387 - Crosswalk of Changes - MDS 3.0 Item Set.pdf Crosswalk of Changes	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

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)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 413.343 42 CFR 424.32 42 CFR 483.20 42 CFR 413.337

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10387		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10387	https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Long Term Care-Minimum Data Set'' (MDS), System No. 09-70-1517

FR Citation: 72 FR 12801

Number of Respondents: 15,253

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,784,397	-684,786	3,469,183
Annual IC Time Burden (Hours)	2,682,974	-178,377	2,861,351
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Crosswalk of Changes		09/02/2025

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

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