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)

Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) for the Collection of Data Related to the Patient Driven Payment Model and the Skilled Nursing Facility QRP (CMS-10387)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1140 can be found here:

Documents and Forms

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
CMS-10387 Nursing Home PPS (NP) Item Set MDS3.0_NP_PPS_v1.17.1.pdf Form and Instruction
CMS-10387 Nursing Home and Swing Bed OMRA (NO/SO) Item Set MDS3.0_NO_SO_OMRA-Other_v1.16.1.pdf Form and Instruction
CMS-10387 Long-Term Care Facility Resident Assessment Instrument ( MDS RAI Manual v1.16 PRA cover page.pdf downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.1.pdf Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set MDS3.0_IPA_v1.17.1.pdf Form and Instruction
CMS-10387 Proposed Data Elements (60.5 New Elements) Proposed-SNF-QRP-Items-Mockup-Effective-October-1-2020.pdf www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-o Form and Instruction

Information Collection (IC) Details

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 483.20 42 CFR 424.32 42 CFR 413.343 42 CFR 413.337

Information Collection Instruments:

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	MDS3.0_NP_PPS_v1.17.1.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10387	Nursing Home and Swing Bed OMRA (NO/SO) Item Set	MDS3.0_NO_SO_OMRA-Other_v1.16.1.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-10387	Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (Cover Only)	MDS RAI Manual v1.16 PRA cover page.pdf	https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Nursing Home Part A PPS Discharge (NPE) Item Set	MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.1.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Interim Payment Assessment (IPA) Item Set	MDS3.0_IPA_v1.17.1.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Proposed Data Elements (60.5 New Elements)	Proposed-SNF-QRP-Items-Mockup-Effective-October-1-2020.pdf	https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-Downloads-and-Videos.html	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,471	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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	4,905,042	4,905,042
Annual IC Time Burden (Hours)	4,169,286	4,169,286
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.