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OMB Control No: 0938-0273	ICR Reference No: 202406-0938-004
Status: Active	Previous ICR Reference No: 202101-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy (OPT) and/or Speech Pathology Services (OSP)- Initial and Extension Site Requests (CMS-381)
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: 07/31/2024
	Date Received in OIRA: 06/12/2024
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	506	0	443
Time Burden (Hours)	253	0	111
Cost Burden (Dollars)	0	0	0

Abstract: As a result of recent certification process changes (Admin Info 22-02), CMS is revising the Form CMS-381 to streamline the certification processes for initial enrollment of an OPT/OSP. The Form CMS 381 is revised to reflect previous information on the Form CMS 1856 (which will be discontinued) and updated information for Medicare providers of Outpatient Physical Therapy and Speech Pathology Services (OPT) providing services at additional locations in addition to their Medicare approved primary site. These additional locations are called “extension locations” and must be reported by the provider and approved by CMS. Form CMS-381 provides a method for OPT providers to meet this reporting requirement. The revised form will be used for initial enrollment and requests for extension locations/sites.

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:
	89 FR 20658	03/25/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 49178	06/11/2024
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381)	CMS-381

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	506	443	63
Annual Time Burden (Hours)	253	111	142
Annual Cost Burden (Dollars)	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: While the burden for this data collection appears to have increased from the previous collection, we note that as a result of this revision, form CMS-1856 will be discontinued for use. The form CMS-1856 was required for all prospective OPT providers to be completed for initial enrollment. Given the information above, 78 new OPT providers would have needed to complete the CMS-1856 form by the equivalent of a Healthcare Support Staff (Healthcare Support Occupations). The support staff with a mean hourly wage of $16.02 which is $32.04, including fringe benefits, based on the Bureau of Labor Statistics National Occupational Employment and Wage Estimates (https://www.bls.gov/oes/current/oes310000.htm). Therefore, previously had a total annual cost would be $624.78 for all new prospective OPT providers to complete this form upon initial enrollment. Since CMS has combined content of form CMS-1856 with this new revised form CMS-381 has increased the time for completion by 15 minutes, however has omitted the annual cost of $624.78. The revised CMS-381 would be at an annual cost of $8,106. If taking the saving of $624.78, the cost would be $3,415.22, which is a minor increase reflective of annual inflation and therefore could be considered a saving. For the revised CMS-381, we have increased the time burden for this data collection from 111 hours to 253 hours. This is a 142 hour increase in the time burden. We have also increased the cost burden associated with this data collection from $3,116.60 to $8,106. This is as a result of the combined forms.

Annual Cost to Federal Government: $13,579

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

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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