(CMS-1856) Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-1856 Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729 Form and Instruction	Modified
CMS-1856 Response_to_Public_Comments 8-6-21.docx Supplementary Document	2021-08-13
CMS-1856 Supporting Statement (CLEAN 6-1-21).docx Supporting Statement A	2021-08-13

IC Document Collections

IC ID	Document Title	Status
7822	Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0065	ICR Reference No: 202108-0938-005
Status: Received in OIRA	Previous ICR Reference No: 201805-0938-014
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: (CMS-1856) Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulations
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/13/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2021
Responses	195	350
Time Burden (Hours)	49	88
Cost Burden (Dollars)	0	0

---

Abstract: The Medicare Program surveys providers of outpatient physical therapy and sppech-language patholgy services to determine compliance with Federal Regulations. The request for certification form is used by State Agency surveyors to determine if minimum Medicare eligibility requirements are met. The survey report form records the result of the on-site survey.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 30049	06/04/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 44730	08/13/2021
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Outpatient Physical Therapy Speech Pathology Survey Report and Supporting Regulation in 42 CFR 485.701-485.729	CMS-1856	Request for Certification in the Medicare and/or Medicaid Program

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	195	350	0	0	-155	0
Annual Time Burden (Hours)	49	88	0	0	-39	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden adjustment results from decrease in the estimated hourly wage of workers completing these forms. We have updated the hourly wage to reflect anticipated cost that is based on data from the Bureau of Labor Statistics National Occupational Employment and Wage Estimates for May, 2020. For form CMS-1856, we are using the average hourly wage of $31.00 per hour for a healthcare support staff (Healthcare Support Occupations). We have adjusted the individual completing this form to be an administrative support person, not a manager. Overall, the adjustments have decreased the cost burden based on these changes and based on our analysis that approximately 195 OPT/OSP providers which completed this form annually (initial and recertification surveys). The respondents decreased from 350 to 195.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/13/2021

---