Information Collection

MS-DRG classification change requests

IC 248700 under ICR 202509-0938-007 · OMB 0938-1431.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10775 MS-DRG classification change requests	Form and Instruction
Form CMS-10775 MEARIS Login ScreenShots MS-DRG classification change requests	Form and Instruction
Form CMS-10775 New and Revised Medicare Severity Diagnosis Related Groups (MS-DRG) Request MS-DRG classification change requests	Form and Instruction
CMS-10775 MEARIS Login ScreenShots MEARIS Login ScreenShots.docx	Form and Instruction
CMS-10775 MEARIS Login ScreenShots MEARIS Login ScreenShots.docx	Form and Instruction
CMS-10775 New and Revised Medicare Severity Diagnosis Related Grou New and Revised Medicare Severity Diagnosis Related Groups (MS-DRG) Request.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 412.60

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 and Instruction	CMS-10775				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10775				No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	48,000	48,000
Annual IC Cost Burden (Dollars)	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.

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