Home Health Face-to-Face Encounter Clinical Templates (CMS-10564)

Forms and Documents

Document Name	Status
Form CMS-10564 Physician Annual Burden for Completing the Electronic and Paper Clinical Template Form and Instruction	New
CMS-10564 Supporting Statement Part A - FINAL 11-30-16.docx Supporting Statement A	2016-12-01
Revision to Form CMS 10564 Home Health .docx Supplementary Document	2015-12-28
Final Responses to HH Template PRA Comments.docx Supplementary Document	2015-12-28

IC Document Collections

IC ID	Document Title	Status
219423	Physician Annual Burden for Completing the Electronic and Paper Clinical Template Form and Instruction	New

ICR Details

OMB Control No: 0938-1318	ICR Reference No: 201512-0938-012
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Home Health Face-to-Face Encounter Clinical Templates (CMS-10564)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/09/2016
	Date Received in OIRA: 12/29/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved
Responses	2,926,420	0	0
Time Burden (Hours)	1,220,317	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CMS has developed home health templates to assist with documenting a home health face-to-face examination. CMS believes the use of the progress note templates may help assist physicians when documenting the home health (HH) face-to-face encounter for Medicare purposes. The use of these templates will be completely voluntary and is intended only to assist physicians and other practitioners who order home health services in documenting the required elements in their progress notes.

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Authorizing Statute(s): None

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:
	80 FR 48320	08/12/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 80771	12/28/2015
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
Physician Annual Burden for Completing the Electronic and Paper Clinical Template	CMS-10564	Progress Note and Guidance

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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	2,926,420	0	0	2,926,420	0	0
Annual Time Burden (Hours)	1,220,317	0	0	1,220,317	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: This is a new information collection request.

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Annual Cost to Federal Government: $0

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

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: 12/29/2015

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