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)

OMB: 0938-1140

IC ID: 197759

⚠️ Notice: This information collection may be referencing outdated material.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_v1.17.2.pdf Form and Instruction
CMS-10387 Nursing Home PPS (NP) Item Set MDS3.0_NP_PPS_v1.17.2.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 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_v1.17.2.pdf Form and Instruction
CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set MDS3.0_NPE_Part_A_PPS_Discharge_v1.17.2.pdf Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set MDS3.0_IPA_v1.17.2.pdf Form and Instruction
CMS-10387 Interim Payment Assessment (IPA) Item Set MDS3.0_IPA_v1.17.2.pdf Form and Instruction
CMS-10387 Swing Bed Discharge (SD) Item Set MDS3.0_SD_Dschg_v1.17.2.pdf Form and Instruction
CMS-10387 Swing Bed Discharge (SD) Item Set MDS3.0_SD_Dschg_v1.17.2.pdf Form and Instruction
CMS-10387 Swing Bed PPS (SP) Item Set MDS3.0_SP_PPS_v1.17.2.pdf Form and Instruction
CMS-10387 Swing Bed PPS (SP) Item Set MDS3.0_SP_PPS_v1.17.2.pdf Form and Instruction
MDS3.0_Item_Changes_v1.17.2.pdf Crosswalk IC Document
MDS3.0_Item_Changes_v1.17.2.pdf Crosswalk IC Document
MDS3.0_NC_Comp_v1.17.2.pdf Nursing Home Comprehensive (NC) Item Set. IC Document
MDS3.0_ND_Dschg_v1.17.2.pdf Nursing Home Discharge (ND) Item Set IC Document
MDS3.0_NQ_Quarterly_v1.17.2.pdf Nursing Home Quarterly (NQ) Item Set IC Document
MDS3.0_NT_ST_Track_v1.17.2.pdf Nursing Home and Swing Bed Tracking (NT/ST) Item Set. IC Document
MDS3.0_OSA_v1.17.2.pdf Optional State Assessment (OSA) Item Set IC Document
PRA Screenshot.docx Screenshot of PRA disclosure statement 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 424.32 42 CFR 413.343 42 CFR 483.20 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_v1.17.2.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_v1.17.2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Interim Payment Assessment (IPA) Item Set	MDS3.0_IPA_v1.17.2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Swing Bed Discharge (SD) Item Set	MDS3.0_SD_Dschg_v1.17.2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10387	Swing Bed PPS (SP) Item Set	MDS3.0_SP_PPS_v1.17.2.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	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
Crosswalk	MDS3.0_Item_Changes_v1.17.2.pdf	06/10/2022
Screenshot of PRA disclosure statement	PRA Screenshot.docx	11/21/2022

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