Crosswalk

Revisions to CMS-417 Form –
Comprehensive Outpatient Rehabilitation Facility Report

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1

Section,
Row &
Column
Section 1
Row 2,
Column 3

Changes Made to the CMS-417 Form
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Reasons for the Change

Change the title of this data field on the existing •
CMS-417 form from “City, County & State”
to

“City & State” on the existing CMS-417 form

Add a new separate data field for “County” in
row 3, column 2 on the revised CMS-417 form.

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Section 1
Row 3,
Column 2

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Delete the title of this data field on the existing •
version of the CMS-417 form in section 1, row
3, column 2, titled: “Medicare Certification No.
(CCN)”
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Add the following new title “County” to this
data field on the revised CMS-417 form
•
We have relocated the data field for CCN
number to row 3, column 5 on the revised
CMS-417 form.

We have made this change because it is not typical to
include the county name in an address. However, we still
want to capture this information. So, we added a new,
separate data field to collect the county name in row 3,
column 2.

Also, on the existing version of the CMS-417 form, there
are 2 fields that collect the county name. One is located at
row 2, column 3 and is titled as “City, County & State.”
The 2nd is located at row 3, column 3 and is titled
“State/County.”
There is no need to collect the county name twice.

We have made this change so that we can add a new,
separate data field for the name of the county in which
the hospice is located on the revised CMS-417 form.
We believe this information should be collected
separately from the hospice’s address.

We still need to collect the hospice’s CCN number so we
have relocated the data field for CCN number to another
location on the revised CMS-417 form.

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1

Section,
Row &
Column
Section 1,
Row 3,
Column 3

Changes Made to the CMS-417 Form
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Delete the title of the data field at row 3,
column 3 on the existing CMS-417 form titled
“State/County” to “Region” on the revised
CMS-417 form

Reasons for the Change
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Section 1,
Row 3,
Column 4

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Delete the title of the data field at row 3,
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column 4 on the existing CMS-417 form titled
“Region/State” to “Telephone Number” on the
revised CMS-417 form
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•

We made this change because we have added a separate
data field at row 3, column 2 titled “County” on the
revised CMS-417 form.

Also, on the existing version of the CMS-417 form, there
are 2 fields that collect the county name. One is located at
row 2, column 3 and is titled as “City, County & State.”
The 2nd is located at row 3, column 3 and is titled
“State/County.”
There is no need to collect the county name twice.

We made this change because we are already collecting
the State with the address, therefore it is not necessary to
collect this information twice.

Also, we have changed the data field on the existing
version of the CMS-417 form titled “State/County” to
“Region” at row 3, column 3, on the existing version of
the CMS-417 form.
This change will allow us to still collect the Region
number.

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1

1

Section,
Row &
Column
Section 1,
Row 3,
Column 5

Section 1,
Row 3,
Column 6

Changes Made to the CMS-417 Form
•

•

Reasons for the Change

Delete the title of the data field at row 3,
column 5 on the existing CMS-417 form titled:
“Telephone Number” to “Hospice’s CCN
Number” on the revised CMS-417 form.

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Change the title of the data field at row 3,
column 6 on the existing version of the CMS417 form titled “Related Certification No.” to
“Related Facility CCN” on the revised version
of the CMS-417 form.

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2

Section 2,
Rows 1 & 2

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Change the contents of section II from “Type of
Hospice” on the existing CMS-417 form to “AO
Information” on the revised CMS-417 form.

This revised data field on the revised version of
the CMS-417 form collects the name of the AO
that accredits the hospice.
Relocated the “Type of Hospice” data field to
section 3 and rename to “Hospice Affiliation”

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•

We have relocated the data field for the hospice’s CCN
number from row 3, column 2 on the existing version of
the CMS-417 form to row 3, column 5 on the revised CMS417 form.
We made this change because we are revising the data
fields on the CMS-417 form and this has caused some
shuffling around of the data fields.

The purpose of this data field is to collect the CCN number
of a facility with which a hospice is associated.
However, we believe that the title of this data field on the
existing CMS-417 form of “Related Certification No.” is
vague and does not properly convey what information is
sought,
We have changed the title of this data item to “Related
Facility CCN” on the revised CMS-417 form for clarity.

This is not a new data field and no changes to the text of
this data field.

We have simply relocated this data field in the process of
revising the CMS-417 form.

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1

1

2

Section,
Row &
Column
Section 2,
Column 4

Changes Made to the CMS-417 Form
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Title these data fields on the revised version of
the CMS-417 form as:
o Start Date of Last Survey:
o End Date of Last Survey:

New section 3,
Rows 1,2, & 3
Columns 1, 2 &
3

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Relocate the section titled “Type of Hospice”
on the existing version of the CMS-417 form to
section 3.

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New section 4

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Relocate the section 3 titled “Type of Control”
on page 1 of the existing version of the CMS417 form to page 2 as section 4 on the revised
CMS-417 form.

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3

Split the data field titled “Fiscal Year Ending
Date” on the existing version of the CMS-417
form into 2 separate data forms in the same
location on the revised CMS-417 form.

Reasons for the Change

New section 5

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Rename section as “Hospice Affiliation”

Keep the same title, column titles and
selections with minor changes.

Relocate the section titled “IV. Services
Provided” on the existing version of the CMS-

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We made this change because, we do not believe that the
fiscal year ending date is helpful information to collect.

Instead of deleting this data field completely, we have
added the start and end dates for the hospices last survey.
This would be helpful information to the State Survey
Agency.

This is not a new data field and no changes to the text of
this data field.

We have simply relocated this data field in the process of
revising the CMS-417 form.
This is not a new data field

We have made slight modifications to the titles of the 2nd
and 3rd columns for clarity. These modifications do not
alter the meaning of the titles.

We have also made slight modifications to selections 12 &
13 under column 3. These alterations are for clarity only
and do not alter the meanings of these selections.
In the existing version of the CMS-417, the “How Services
is Provided” is squished into the top quarter of page 2.

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Section,
Row &
Column

Changes Made to the CMS-417 Form

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417 form to page 3 through 6 on the revised
version of the CMS-417 form.
We reformatted this section by doing the
following:

o In column 2, for we provided a separate
row listing each of the 11 hospice
services and 2 additional rows for
additional hospice services to be
specified.
o In column 3, we provided 4 sub-rows
per each hospice service.
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Reasons for the Change
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The person completing the existing version of the CMS417 form is directed to add a number in a box to indicate
how each service is provided.
These numbers are explained in column 1 of this section
as follows:
o If by staff, place a “1” in the block(s);

o If under arrangement, place a “2” in the block(s);
o If by staff and arrangement, place a “3” in the
block(s).

We made these changes for several reasons. First, we believe
that the formatting of this data field on the existing version of
In these sub-rows, we provided 3 the CMS-417 form is squished into too small a space making
different descriptions of how the it hard to view, understand and complete.
hospice service could be
We also believe that using numbers to provide a response is
provided by the hospice
(i.e. - (1) directly by the hospice; not the best way to collect responses to this data field and
that this data field could be vastly improved upon.
(2) by contract with an outside
party; (3) by arrangement with
Also, we believe that the explanations for the numbered
another certified hospice.)
responses are vague and limited in scope and should be
improved upon.
We also provided a selection of
th
“not applicable” in the 4 subrow that can be used to indicate
that the hospice does not provide
a particular service.
We also added a fillable check
box in each of the sub-rows to
allow the hospice staff to select
the description that most

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Section,
Row &
Column

Changes Made to the CMS-417 Form

Reasons for the Change

accurately describes how that
hospice provides the service.

o In row 4, we added a separate data field
for the name and address for the Other
Certified Hospice or Outside Contractor
for each of the 11 services listed and
also for the 2 additional services to be
specified (if applicable).
o In row 5, we added a separate data field
for the CCN for the other certified
Hospice or supplier number for outside
contractor (if any) for each of the 11
services listed and also for the 2
additional services to be specified (if
applicable).
Page 2
on
existing
CMS-417
form

New Page 7
(on revised
CMS-417)
Previous
section 5
New section 6

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Due to the reformatting of the revised version
of the CMS-417 form, the number of this
section has been changes from 4 on the
existing version of the CMS-417 form to 5 on
the revised version of the CMS-417 form.

This data field has also been moved from page
2 on the existing CMS-417 form to page 7 on
the revised version of the CMS-417 form.
We changed to title of this section from:
“Number Of Employees –
(Including Full-Time Volunteers)”

to

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We made the changes to the title of this section because
we believe that is more descriptive of the purpose for this
data collection and the type of information being
collected. For example, the title of this section on the
existing version of the CMS-417 form is “Number of
Employees – (Including Full-Time Volunteers).

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This title seems to indicate that the purpose of this section is
to collect information about the number of employees and
full-time volunteers at the hospice completing the CMS-417
form.

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The actual purpose of this data item is to collect the
annual number of full-time equivalents (FTEs) for all

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Section,
Row &
Column

Changes Made to the CMS-417 Form

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Reasons for the Change

“Full-Time Equivalents for Employees and Volunteers
Full-Time Equivalents for Employees and Volunteers”

hospice employees and full-time volunteers broken down
by employee and volunteer type.

We changed the title of column 3 from:

o The Full-Time Equivalent (FTE) is a unit of
measurement that allows organizations to measure
and standardize workforce capacity across different
employment types.

“Number of Employees”
to
“Hospice Employee Full-Time
Equivalents (FTEs)”

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We changed the title of column 4 from:
“Number of Full-Time Volunteers”
to
“Hospice Volunteer Full-Time
Equivalents (FTEs)”

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o The FTE is a measure of the sum total work hours put
in by all employees compared to those worked by one
full time worker.
We believe that the new title of “Full-Time Equivalents
for Hospice Employees and Volunteers” on the revised
CMS-417 form reflects the actual purpose of this data
item.
We also changed the titles to columns 3 and 4 because
they also did not reflect the purpose of this data
collection.
o

o

For example, the title of column 3 on the existing
version of the CMS-417 form is “Number of

Employees.” This data item in not intended to collect
information about the number of hospice employees, but
instead about the number of FTEs for the hospice
employees.

Therefore, we changed the title of column 3 on the revised
CMS-417 for to “Hospice Employee Full-Time Equivalents
(FTEs)” because this reflects the type of information to be
collected

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Section,
Row &
Column

Changes Made to the CMS-417 Form

Reasons for the Change
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Finally, we changed the title of columns 4 because it did
not reflect the purpose of this data collection.
o

For example, the title of column 4 on the existing
version of the CMS-417 form is “Number of Full Time
Volunteers.”

o

o

Page 3
on
existing
version
of the
CMS-417
form

Page 8
•
(revised
version of
CMS-417 form)
Attestation
Statement
section

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Add a fillable .pdf data field for “Title of
Hospice Representative”

As this data item is not intended to collect information
about the number of hospice volunteers, but instead
about the number of FTEs for the full-time hospice
volunteers.
We changed the title of column 4 on the revised CMS417 for to “Hospice Volunteer Full-Time Equivalents
(FTEs)” because we believe that this revised title
reflects the type of information to be collected.

We added this data field to the revised version of the CMS417 form because we believe that it is important to collect
information about the title or credentials of the person
completing and signing the CMS-417 form. This information
could be useful to determine whether this person had the
authority to complete and sign the CMS-417 form.