Version 5010/ICD-10 Industry Readiness Assessment

Forms and Documents

Document Name	Status
Form CMS-10381 Survey Form	Modified
CMS-10381.Supporting Statement Part B.docx Supporting Statement B	2013-03-05
CMS-10381.Crosswalk of changes to Survey Instruments.docx Supplementary Document	2013-03-05
CMS-10381.Supporting Statement Part A.docx Supporting Statement A	2013-03-05

IC Document Collections

IC ID	Document Title	Status
198380	Survey Form	Modified

ICR Details

OMB Control No: 0938-1149	ICR Reference No: 201303-0938-006
Status: Historical Active	Previous ICR Reference No: 201107-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: 19077
Title: Version 5010/ICD-10 Industry Readiness Assessment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/10/2013
	Date Received in OIRA: 03/08/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	10/31/2014
Responses	1,200	0	600
Time Burden (Hours)	204	0	150
Cost Burden (Dollars)	0	0	0

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Abstract: Findings from the ICD-10 industry readiness assessment will be used by CMS to understand each sector's progress toward compliance and to determine what communication and educational efforts can best help affected entities obtain the tools and resources they need to achieve timely compliance with ICD-10. Respondents to this information collection are health care providers, payers, and vendors.

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Authorizing Statute(s): PL: Pub.L. 104 - 191 1171-1180 Name of Law: HIPAA
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 47852	12/07/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 79099	12/07/2012
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Survey	CMS-10381, CMS-10381, CMS-10381	CMS-10381.Appendix C Respondent Letters Version 5010 ICD10 Readiness Assessment ,   Appendix D1 ICD 10 industry readiness assessment questionnaire ,   Appendix D2 ICD 10 readiness assessment questionnaire for post deadline fielding

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ICR Summary of Burden

	Total Approved	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	1,200	600	0	600	0	0
Annual Time Burden (Hours)	204	150	0	54	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The revised survey has been revised to account for the new deadline and to add text that clarifies three questions. A second survey instrument (Appendix D-2) is also based on the previously approved instrument, but is further modified for the final data collection, to occur after the ICD-10 compliance deadline. Text in the second survey is reworded to account for the fact that respondents should already be ICD-10-compliant by the fielding date.

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Annual Cost to Federal Government: $268,500

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 03/08/2013

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