[Federal Register Volume 59, Number 52 (Thursday, March 17, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-6153]
[[Page Unknown]]
[Federal Register: March 17, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[OIS-024-N]
Medicare and Medicaid Programs; Quarterly Listing of Program
Issuances and Coverage Decisions--Fourth Quarter 1993
AGENCY: Health Care Financing Administration (HCFA), HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This notice lists HCFA manual instructions, substantive and
interpretive regulations and other Federal Register notices, and
statements of policy that were published during October, November, and
December of 1993 that relate to the Medicare and Medicaid programs.
Section 1871(c) of the Social Security Act requires that we publish a
list of Medicare issuances in the Federal Register at least every 3
months. Although we are not mandated to do so by statute, for the sake
of completeness of the listing, we are including all Medicaid issuances
and Medicare and Medicaid substantive and interpretive regulations
(proposed and final) published during this timeframe.
We are also providing the content of revisions to the Medicare
Coverage Issues Manual published between October 1 and December 31,
1993. On August 21, 1989 (54 FR 34555), we published the content of the
Manual and indicated that we will publish quarterly any updates. Adding
to this listing the complete text of the changes to the Medicare
Coverage Issues Manual allows us to fulfill this requirement in a
manner that facilitates identification of coverage and other changes in
our manuals.
FOR FURTHER INFORMATION CONTACT:
Margaret Cotton, (410) 966-5260 (For Medicare instruction information)
Walter Rutemueller, (410) 966-5395 (For Medicare coverage information)
Pat Prete, (410) 965-3246 (For Medicaid instruction information)
Jacqueline Kidd, (410) 966-4682 (For all other information)
SUPPLEMENTARY INFORMATION:
I. Program Issuances
The Health Care Financing Administration (HCFA) is responsible for
administering the Medicare and Medicaid programs, which pay for health
care and related services for 36 million Medicare beneficiaries and 33
million Medicaid recipients. Administration of these programs involves
(1) Providing information to Medicare beneficiaries and Medicaid
recipients, health care providers, and the public; and (2) effective
communications with regional offices, State governments, State Medicaid
Agencies, State Survey Agencies, various providers of health care,
fiscal intermediaries and carriers who process claims and pay bills,
and others. To implement the various statutes on which the programs are
based, we issue regulations under authority granted the Secretary under
sections 1102, 1871, and 1902 and related provisions of the Social
Security Act (the Act) and also issue various manuals, memoranda, and
statements necessary to administer the programs efficiently.
Section 1871(c)(1) of the Act requires that we publish in the
Federal Register at least every 3 months a list of all Medicare manual
instructions, interpretive rules, statements of policy, and guidelines
of general applicability not issued as regulations. We published our
first notice June 9, 1988 (53 FR 21730). Although we are not mandated
to do so by statute, for the sake of completeness of the listing of
operational and policy statements, we are continuing our practice of
including Medicare substantive and interpretive regulations (proposed
and final) published during the 3-month timeframe. Since the
publication of our quarterly listing on June 12, 1992 (57 FR 24797), we
decided to add Medicaid issuances to our quarterly listings.
Accordingly, we are listing in this notice Medicaid issuances and
Medicaid substantive and interpretive regulations published from
October 1 through December 30, 1993.
II. Medicare Coverage Issues
We receive numerous inquiries from the general public about whether
specific items or services are covered under Medicare. Providers,
carriers, and intermediaries have copies of the Medicare Coverage
Issues Manual, which identifies those medical items, services,
technologies, or treatment procedures that can be paid for under
Medicare. On August 21, 1989, we published a notice in the Federal
Register (54 FR 34555) that contained all the Medicare coverage
decisions issued in that manual.
In that notice, we indicated that revisions to the Coverage Issues
Manual will be published at least quarterly in the Federal Register. We
also sometimes issue proposed or final national coverage decision
changes in separate Federal Register notices. Readers should find this
an easy way to identify both issuance changes to all our manuals and
the text of changes to the Coverage Issues Manual.
Revisions to the Coverage Issues Manual are not published on a
regular basis but on an as-needed basis. We publish revisions as a
result of technological changes, medical practice changes, responses to
inquiries we receive seeking clarifications, or the resolution of
coverage issues under Medicare. If no Coverage Issues Manual revisions
were published during a particular quarter, our listing will reflect
that fact.
Not all revisions to the Coverage Issues Manual contain major
changes. As with any instruction, sometimes minor clarifications or
revisions are made within the text. We have reprinted manual revisions
as transmitted to manual holders. The new text is shown in italics. We
will not reprint the table of contents, since the table of contents
serves primarily as a finding aid for the user of the manual and does
not identify items as covered or not.
III. How To Use the Addenda
This notice is organized so that a reader may review the subjects
of all manual issuances, memoranda, substantive and interpretive
regulations, or coverage decisions published during the timeframe to
determine whether any are of particular interest. We expect it to be
used in concert with previously published notices. Most notably, those
unfamiliar with a description of our Medicare manuals may wish to
review Table I of our first three notices (53 FR 21730, 53 FR 36891,
and 53 FR 50577) and the notice published March 31, 1993 (58 FR 16837),
and those desiring information on the Medicare Coverage Issues Manual
may wish to review the August 21, 1989, publication.
To aid the reader, we have organized and divided this current
listing into five addenda. Addendum I identifies updates that changed
the Coverage Issues Manual. We published notices in the Federal
Register that included the text of changes to the Coverage Issues
Manual. These updates, when added to material from the manual published
on August 21, 1989, constitute a complete manual as of March 31, 1993.
Parties interested in obtaining a copy of the manual and revisions
should follow the instructions in section IV of this notice.
Addendum II identifies previous Federal Register documents that
contain a description of all previously published HCFA Medicare and
Medicaid manuals and memoranda.
Addendum III of this notice lists, for each of our manuals or
Program Memoranda, a HCFA transmittal number unique to that instruction
and its subject matter. A transmittal may consist of a single
instruction or many. Often it is necessary to use information in a
transmittal in conjunction with information currently in the manuals.
Addendum IV lists all substantive and interpretive Medicare and
Medicaid regulations and general notices published in the Federal
Register during the quarter covered by this notice. For each item, we
list the date published, the Federal Register citation, the title of
the regulation, and the Parts of the Code of Federal Regulations (CFR)
which have changed.
Addendum V sets forth the revisions to the Medicare Coverage Issues
Manual that were published during the quarter covered by this notice.
For the revisions, we give a brief synopsis of the revisions as they
appear on the transmittal sheet, the manual section number, and the
title of the section. We present a complete copy of the revised
material, no matter how minor the revision, and identify the revisions
by printing in italics the text that was changed. If the transmittal
includes material unrelated to the revised section, for example, when
the addition of revised material causes other sections to be
repaginated, we do not reprint the unrelated material.
IV. How To Obtain Listed Material
A. Manuals
An individual or organization interested in routinely receiving any
manual and revisions to it may purchase a subscription to that manual.
Those wishing to subscribe should contact either the Government
Printing Office (GPO) or the National Technical Information Service
(NTIS) at the following addresses:
Superintendent of Documents, Government Printing Office, ATTN: New
Order, P.O. Box 371954, Pittsburgh, PA 15250-7954, Telephone (202) 783-
3238, Fax number (202) 512-2250 (for credit card orders); or
National Technical Information Service, Department of Commerce, 5825
Port Royal Road, Springfield, VA 22161, Telephone (703) 487-4630.
In addition, individual manual transmittals and Program Memoranda
listed in this notice can be purchased from NTIS. Interested parties
should identify the transmittal(s) they want. GPO or NTIS can give
complete details on how to obtain the publications they sell.
B. Regulations and Notices
Regulations and notices are published in the daily Federal
Register. Interested individuals may purchase individual copies or
subscribe to the Federal Register by contacting the GPO at the address
indicated above. When ordering individual copies, it is necessary to
cite either the date of publication or the volume number and page
number.
C. Rulings
Rulings are published on an infrequent basis by HCFA. Interested
individuals can obtain copies from the nearest HCFA Regional Office or
review them at the nearest regional depository library. We also
sometimes publish Rulings in the Federal Register.
D. HCFA's Compact Disk-Read Only Memory (CD-ROM)
HCFA's laws, regulations, and manuals are now available on CD-ROM,
which may be purchased from GPO or NTIS on a subscription or single
copy basis. The Superintendent of Documents list ID is HCLRM, and the
stock number is 717-139-00000-3. The following material is contained on
the CD-ROM disk:
Titles XI, XVIII, and XIX of the Act.
HCFA-related regulations.
HCFA manuals and monthly revisions.
HCFA program memoranda.
The titles are current as of the September 1, 1992, update of the
Compilation of the Social Security Laws and the regulations are those
in effect as of October 1, 1993.
The CD-ROM disk does not contain Appendices M (Interpretative
Guidelines for Hospices) and R (Resident Assessment for Long Term Care
Facilities) of the State Operations Manual. Copies of these appendices
may be reviewed at a Federal Depository Library (FDL).
Any cost report forms incorporated in the manuals are included on
the CD-ROM disk as LOTUS files. LOTUS software is needed to view the
reports once the files have been copied to a personal computer disk.
V. How To Review Listed Material
Transmittals or Program Memoranda can be reviewed at a local FDL.
Under the FDL program, government publications are sent to
approximately 1400 designated libraries throughout the United States.
Interested parties may examine the documents at any one of the FDLs.
Some may have arrangements to transfer material to a local library not
designated as an FDL. To locate the nearest FDL, individuals should
contact any library.
In addition, individuals may contact regional depository libraries,
which receive and retain at least one copy of most Federal government
publications, either in printed or microfilm form, for use by the
general public. These libraries provide reference services and
interlibrary loans; however, they are not sales outlets. Individuals
may obtain information about the location of the nearest regional
depository library from any library.
Superintendent of Documents numbers for each HCFA publication are
shown in Addendum III, along with the HCFA publication and transmittal
numbers. To help FDLs locate the instruction, use the Superintendent of
Documents number, plus the HCFA transmittal number. For example, to
find the Carriers Manual, Part 2--Program Administration (HCFA-Pub. 14-
2) transmittal entitled ``The Contractor Performance Evaluation
Program--FY 1993,'' use the Superintendent of Documents No. HE 22.8/7-
3, and the HCFA transmittal number 123.
VI. General Information
It is possible that an interested party may have a specific
information need and not be able to determine from the listed
information whether the issuance or regulation would fulfill that need.
Consequently, we are providing information contact persons to answer
general questions concerning these items. Copies are not available
through the contact persons. Copies can be purchased or reviewed as
noted above.
Questions concerning Medicare items in Addenda III may be addressed
to Margaret Cotton, Office of Issuances, Health Care Financing
Administration, Room 688 East High Rise, 6325 Security Blvd.,
Baltimore, MD 21207, Telephone (410) 966-5260.
Questions concerning Medicaid items in Addenda III may be addressed
to Pat Prete, Medicaid Bureau, Office of Medicaid Policy, Health Care
Financing Administration, Room 233 East High Rise, 6325 Security Blvd.,
Baltimore, MD 21207, Telephone (410) 965-3246.
Questions concerning items in Addenda V may be addressed to Walter
Rutemueller, Office of Coverage and Eligibility Policy, Health Care
Financing Administration, Room 401 East High Rise, 6325 Security Blvd.,
Baltimore, MD 21207, Telephone (410) 966-5395.
Questions concerning all other information may be addressed to
Jacqueline Kidd, Regulations Staff, Health Care Financing
Administration, Room 132 East High Rise, 6325 Security Blvd.,
Baltimore, MD 21207, Telephone (410) 966-4682.
(Catalog of Federal Domestic Assistance Program No. 93.773,
Medicare--Hospital Insurance, Program No. 93.774, Medicare--
Supplementary Medical Insurance Program, and Program No. 93.714,
Medical Assistance Program)
Dated: March 7, 1994.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
Addendum I
This addendum lists the publication dates of the quarterly listing
of program issuances and coverage decision updates to the Coverage
Issues Manual.
March 20, 1990 (55 FR 10290)
February 6, 1991 (56 FR 4830)
July 5, 1991 (56 FR 30752)
November 22, 1991 (56 FR 58913)
January 22, 1992 (57 FR 2558)
March 16, 1992 (57 FR 9127)
June 11, 1992 (57 FR 24797)
October 16, 1992 (57 FR 47468)
January 7, 1993 (58 FR 3028)
March 31, 1993 (58 FR 16837)
July 9, 1993 (58 FR 36967)
September 1, 1993 (58 FR 46200)
December 22, 1993 (58 FR 67796)
Addendum II--Description of Manuals, Memoranda, and HCFA Rulings
An extensive descriptive listing of Medicare manuals and memoranda
was published on June 9, 1988, at 53 FR 21730 and supplemented on
September 22, 1988, at 53 FR 36891 and December 16, 1988, at 53 FR
50577. Also, a complete description of the Medicare Coverage Issues
Manual was published on August 21, 1989, at 54 FR 34555. A brief
description of the various Medicaid manuals and memoranda that we
maintain was published on October 16, 1992, at 57 FR 47468.
Addendum III.--Medicare and Medicaid Manual Instructions October Through
December 1993
------------------------------------------------------------------------
Trans. No. Manual/subject/publication number
------------------------------------------------------------------------
Intermediary Manual, Part 2 - Audits, Reimbursement Program
Administration (HCFA-Pub. 13-2) (Superintendent of Documents No. HE
22.8/6-2)
------------------------------------------------------------------------
394............. deg. Completion of the Form HCFA-1885A.
The Contractor Performance Evaluation Program--FY
1993.
Bill Processing and Service Criterion.
Payment Safeguards Criterion.
Service Criterion.
The RHHI Performance Evaluation Program - FY 1993.
Regional Home Health Intermediary Criterion.
------------------------------------------------------------------------
Intermediary Manual, Part 3 - Claims Process (HCFA-Pub. 13-3)
(Superintendent of Documents No. HE 22.8/6)
------------------------------------------------------------------------
1606............ deg. Electronic Media Claims.
File Specifications, Record Specifications, and Data
Element Definitions for EMC Bills.
National Standard Electronic Remittance Advice.
Medicare Standard Electronic PC-Print Software.
1607............ deg. Bill Review for Partial Hospitalization Services
Provided in Community Mental Health Centers.
Hospital Outpatient Partial Hospitalization Services.
Provider Electronic Billing File and Record Formats
HCFA-485 Home Health Certification and Plan of
Treatment.
1608............ deg. PPS PRICER Program.
1609............ deg. Review of Form HCFA-1450 for Inpatient and
Outpatient Bills.
Billing Procedures for Where Medicare Benefits are
Secondary to Group Health Plans for Employed
Beneficiaries/Spouses and the Disabled.
Coding Structures.
MSP Outpatient Claims Involving Lab Charges Paid By
Fee Schedule.
1610............ deg. Rules Governing Charges to Beneficiaries.
The Intermediary Workload Report, Form HCFA-1566.
1611............ deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Intermediary Manual, Part 4 - Audit Procedures (HCFA-Pub. 13-3)
(Superintendent of Documents No. HE 22.8/6-4)
------------------------------------------------------------------------
31.............. deg. Introduction to the Home Health Agency Uniform
Desk Review.
Instructions for Performing Desk Reviews.
32.............. deg. General.
Revised Medicare Audit Process.
------------------------------------------------------------------------
Carriers Manual, Part 2 - Program Administration (HCFA-Pub. 14-2)
(Superintendent of Documents No. HE 22.8/7-3)
------------------------------------------------------------------------
123............. deg. The Contractor Performance Evaluation Program -
FY 1993.
Claims Processing Criterion.
Payment Safeguards Criterion.
Service Criterion.
CWF Host Performance Evaluation Program - FY 1993.
124............. deg. Functional Standards for Claims Processing
Operations.
------------------------------------------------------------------------
Carriers Manual, Part 3 - Claims Process (HCFA-Pub. 14-3)
(Superintendent of Documents No. HE 22.8/7)
------------------------------------------------------------------------
1465............ deg. List of Covered Surgical Procedures.
1466............ deg. Requirement for Processing Electronic Media
Claims.
The System for Processing Electronic Media Claims.
EMC Testing and Verification.
Technical Requirements.
Data Sets and Formats for Electronic Media Claims and
Electronic Remittance Advice.
1467............ deg. Bills Involving Medical Assistance Recipients.
Processing Claims for Services of Participating
Physicians or Suppliers.
Physician and Supplier Billing Requirements for
Services Furnished on or After September 1, 1990.
Participation Program.
1468............ deg. Psychological Tests.
1469............ deg. The Carrier Performance Report, HCFA-1565.
1470............ deg. Nonparticipating Physicians to Provide Notices
for Elective Surgery.
Handling Beneficiary Complaints.
1471............ deg. Technical Specifications of the EOMB.
1472............ deg. Epoetin Furnished to ESRD Home Patients.
1473............ deg. Introduction.
Definition of a Global Surgical Package.
Billing Requirements for Global Surgeries.
Claims Review for Global Surgeries.
Adjudication of Claims for Global Surgeries.
Postpayment Issues.
Claims for Multiple Surgeries.
Claims for Bilateral Surgeries.
Procedures Billed With Two or More Surgical Modifiers.
Claims for Anesthesia Services Performed On or After
January 1, 1992.
Billing for Portable X-Ray Set-Up Services.
Claims Processing System Requirements.
1474............ deg. Routine Services and Appliances.
Foot Care and Supportive Devices for the Feet.
------------------------------------------------------------------------
Program Memorandum, Intermediaries (HCFA-Pub. 60A) (Superintendent of
Documents No. HE 22.8/6-5)
------------------------------------------------------------------------
A-93-4.......... deg. Change in Hospice Payment Rates.
A-93-5.......... deg. Health Care Financing Administration's Audit and
Cost Report Settlement Expectations.
A-93-6.......... deg. FY 1994 Prospective Payment System and Other
Bill Processing Changes.
------------------------------------------------------------------------
Program Memorandum, Carriers (HCFA-Pub. 60B) (Superintendent of
Documents No. HE 22.8/6-5)
------------------------------------------------------------------------
B-93-5.......... deg. 1994 Physician, Practitioner and Supplier
Participation Enrollment and Fee Schedule Disclosure.
------------------------------------------------------------------------
Program Memorandum, Intermediaries/Carriers (HCFA-Pub. 60 A/B)
(Superintendent of Documents No. HE 22.8/6-5)
------------------------------------------------------------------------
AB-93-5......... deg. Q Code for New Chemotherapy Drug, Paclitaxel.
AB-93-6......... deg. Current Status of Medicare Program Memorandums
and Letters Issued Before Calendar Year 1993.
AB-93-7......... deg. Use of New Code, G0001, for Billing of Routine
Venipuncture.
------------------------------------------------------------------------
Program Memorandum, Medicaid State Agencies (HCFA-Pub. 7)
(Superintendent of Documents No. HE 22.8/6-5)
------------------------------------------------------------------------
93-7............ deg. Current Status of Medicaid Program Memorandums
and Action Transmittals Issued Before Calendar Year
1993.
93-8............ deg. Title XIX, Social Security Act, Medicaid
Coverage and Payment.
------------------------------------------------------------------------
State Operations Manual, Provider Certification (HCFA-Pub. 7)
(Superintendent of Documents No. HE 22.8/12)
------------------------------------------------------------------------
261............. deg. Life Safety Code Surveys.
Conducting Initial Surveys and Scheduled Resurveys.
------------------------------------------------------------------------
Hospital Manual, (HCFA-Pub. 10) (Superintendent of Documents No. HE 22.8/
2)
------------------------------------------------------------------------
655............. deg. Billing for Hospital Outpatient Partial
Hospitalization Services.
Coding Structures.
Completion of Form HCFA-1450 for Inpatient and/or
Outpatient Billing.
656............. deg. Focused Medical Review.
Billing for Part B Outpatient Physical Therapy
Services.
Completion of Form HCFA-1450 for Inpatient and/or
Outpatient Billing.
Medicare Benefits and Secondary to EGHPs for Employed
Beneficiaries/Spouses and the Disabled.
Coding Structures.
MSP Outpatient Claims Involving Lab Charges Paid by
Fee Schedule.
657............. deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Home Health Agency Manual (HCFA-Pub. 11) (Superintendent of Documents
No. HE 22.8/5)
------------------------------------------------------------------------
263............. deg. Billing for Part B Outpatient Physical Therapy
Services.
Focused Medical Review.
264............. deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Skilled Nursing Facility Manual (HCFA-Pub. 12) (Superintendent of
Documents No. HE 22.8/3)
------------------------------------------------------------------------
323............. deg. Focused Medical Review.
Billing for Part B Intermediary OPT Bills.
324............. deg. Rules Governing Charges to Beneficiaries.
325............. deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Rural Health Clinic and Federally Qualified Health Center Manual (HCFA-
Pub. 27) (Superintendent of Documents No. HE 22.8/19:985)
------------------------------------------------------------------------
8............... deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Renal Dialysis Facility Manual (Non-Hospital Operated) (HCFA-Pub. 29)
(Superintendent of Documents No. HE 22.8/13)
------------------------------------------------------------------------
63.............. deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Hospice Manual (HCFA-Pub. 21) (Superintendent of Documents No. HE 22.8/
18)
------------------------------------------------------------------------
38.............. deg. Focused Medical Review.
39.............. deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Outpatient Physical Therapy and Comprehensive Outpatient Rehabilitation
Facility Manual (HCFA-Pub. 9) (Superintendent of Documents No. HE 22.8/
9)
------------------------------------------------------------------------
112............. deg. Focused Medical Review.
Medical Review of Part B OPT Intermediary Bills.
113............. deg. Claims Processing Timeliness.
------------------------------------------------------------------------
Coverage Issues Manual (HCFA-Pub. 6) (Superintendent of Documents No.
HE 22.8/14)
------------------------------------------------------------------------
65.............. deg. Artificial Hearts and Related Devices.
66.............. deg. Medical Documentation.
Laboratory Evidence.
------------------------------------------------------------------------
Provider Reimbursement Manual, Part 1 (HCFA-Pub. 15-1) (Superintendent
of Documents No. HE 22.8/4)
------------------------------------------------------------------------
373............. deg. Regional Medicare Swing-Bed SNF Rates.
374............. deg. Elimination of Payment for Return of Equity.
375............. deg. Costs Not Related to Patient Care.
Political Contribution and Lobbying Activities.
Purpose.
------------------------------------------------------------------------
Provider Reimbursement Manual, Part 1 - Chapter 27 Reimbursement for
ESRD and Transplant Services (HCFA-Pub. 15-1-27) (Superintendent of
Documents No. HE 22.8/4)
------------------------------------------------------------------------
24.............. deg. Items and Services Furnished to Direct Dealing
Home Dialysis Beneficiaries.
25.............. deg. Epoetin.
Infacility Patients.
Home Patients.
------------------------------------------------------------------------
Provider Reimbursement Manual, Part II - Provider Cost Reporting Forms
and Instructions (Chapter 1) (HCFA-Pub. 15-II) (Superintendent of
Documents No. HE 22.8/4)
------------------------------------------------------------------------
16.............. deg. Submission of Cost Report.
------------------------------------------------------------------------
Provider Reimbursement Manual, Part II - Provider Cost Reporting Forms
and Instructions (Chapter 28) (HCFA-Pub. 15-II-AB) (Superintendent of
Documents No. HE 22.8/4)
------------------------------------------------------------------------
3............... deg. Form HCFA-2552-92 Worksheets.
Electronic Reporting Specifications for Form HCFA 2552-
92.
Cost Center Coding.
------------------------------------------------------------------------
Peer Review Organization Manual (HCFA-Pub. 19) (Superintendent of
Documents No. HE 8/8-15)
------------------------------------------------------------------------
25.............. deg. Health Care Financing Administration's Role.
Health Care Quality Improvement Initiative.
Generic Quality Screens - Outpatient Surgery.
Rereview of Quality Concerns.
Scope of PRO Fraud and Abuse Review Activities.
Review Responsibility.
Evaluation Report.
Availability of Expert Witness.
Reopening of Cases.
26.............. deg. Citations and Authority.
Issuances of Hospital Notices of Noncoverage.
Content of Hospital-Issued Notice of Noncoverage.
Beneficiary Request for PRO Review.
Solicitation of Views.
Monitoring Hospital-Issued Notices of Noncoverage.
Beneficiary Liability.
Right to a Reconsideration.
Model Notices of Noncoverage.
Model Hospital Notice Issued to Beneficiary of Pro
Review of Need for Continued Hospitalization.
27.............. deg. Monthly Files.
Review for Approval of Use of an Assistant at Cataract
Surgery.
28.............. deg. Background.
Purpose.
Report of Findings.
Performance Improvement Plan.
------------------------------------------------------------------------
State Medicaid Manual, Part 2 - State Organization and General
Administration (HCFA-Pub. 45-2) (Superintendent of Documents No. HE
22.8/10)
------------------------------------------------------------------------
84.............. deg. Early and Periodic Screening, Diagnostic and
Treatment Report (Form HCFA-416)
------------------------------------------------------------------------
State Medicaid Manual, Part 4 - Services (HCFA-Pub. 45-4)
(Superintendent of Documents No. HE 22.8/10)
------------------------------------------------------------------------
63.............. deg. Authority to Grant Life Safety Code Waivers for
Medicaid Only Certified NFs.
------------------------------------------------------------------------
State Medicaid Manual, Part 5 - Early and Periodic Screening,
Diagnosis, and Treatment (HCFA-Pub. 45-5) (Superintendent of Documents
No. HE 22.8/10)
------------------------------------------------------------------------
6............... deg. Screening Service Content.
7............... deg. Records or Information on Services and
Recipients Annual Participation Goals.
------------------------------------------------------------------------
State Medicaid Manual, Part 6 - Payment for Services (HCFA-Pub. 45-6)
(Superintendent of Documents No. HE 22.8/10)
------------------------------------------------------------------------
24.............. deg. Federal Upper Limit Payments for Multiple Source
Drugs.
------------------------------------------------------------------------
State Medicaid Manual, Part 7 - Quality Control (HCFA-Pub. 45-7)
(Superintendent of Documents No. HE 22.8/10)
------------------------------------------------------------------------
49.............. deg. Definitions of Key Terms.
Medicaid Eligibility Quality Control Review.
MEQC State and Regional Cycles.
Cases Which Are Not Reviewed.
Review of AFDC Cash Cases/Individuals.
In-Person Interview.
Mandatory Use of IEVS Information.
Verification Standards.
Verification Guide.
Administrative Period.
Technical Errors.
Review Month Income Projected Forward Throughout
Spenddown Period.
------------------------------------------------------------------------
Medicare/Medicaid, Sanction--Reinstatement Report (HCFA-Pub. 69)
------------------------------------------------------------------------
93-10........... deg. Report of Physicians/Practitioners, Providers
and/or Other Health Care Suppliers Excluded/
Reinstated.
93-11........... deg. Report of Physicians/Practitioners, Providers
and/or Other Health Care Suppliers Excluded/
Reinstated.
93-12........... deg. Report of Physicians/Practitioners, Providers
and/or Other Health Care Suppliers Excluded/
Reinstated.
93-13........... deg. Report of Physicians/Practitioners, Providers
and/or Other Health Care Suppliers Excluded/
Reinstated.
------------------------------------------------------------------------
Addendum IV.--Regulations and Notices Published July Through September 1993
----------------------------------------------------------------------------------------------------------------
Publication date/citation 42 CFR part Title
----------------------------------------------------------------------------------------------------------------
Final Rules
----------------------------------------------------------------------------------------------------------------
10/01/93 (58 FR 51408)................ 435, 436, Medicaid Program; Eligibility and Coverage Requirements.
440
10/20/93 (58 FR 54045)................ 403 Medicare Program; Demonstration Project to Develop a
Uniform Cost Reporting System for Hospitals.
11/02/93 (58 FR 58502)................ 405, 406, Medicare Program; Self-Implementing Coverage and Payments
409, 410, Provisions: 1990 Legislation (Confirmation of Final
411, 412, Rule).
413, 418,
489
11/18/93 (58 FR 60789)................ 421 Medicare Program; Carrier Jurisdiction for Claims for
Durable Medical Equipment, Prosthetics, Orthotics, and
Supplies (DMEPOS).
11/23/93 (58 FR 61816)................ 401, 488, Medicare Program; Granting and Withdrawal of Deeming
489 Authority to National Accreditation Organizations.
12/02/93 (58 FR 63533)................ 491 Medicare Program Required Laboratory Procedures for Rural
Health Clinics.
12/02/93 (58 FR 63626)................ 405, 414 Medicare Program; Revisions to Payment Policies and
Adjustments to the Relative Value Units Under the
Physician Fee Schedule for Calendar Year 1994.
12/13/93 (58 FR 65126)................ 424 Medicare Program; Intermediary and Carrier Checks That are
Lost, Stolen, Defaced, Mutilated, Destroyed or Paid on
Forged Endorsements.
----------------------------------------------------------------------------------------------------------------
Proposed Rules
----------------------------------------------------------------------------------------------------------------
10/01/93 (58 FR 51288)................ 440, 441 Medicaid Program; Early and Periodic Screening, Diagnosis,
and Treatment Services Defined.
10/15/93 (58 FR 53481)................ 431, 440, Medicaid Program; Case Management.
441, 447
11/26/93 (58 FR 62312)................ 410, 411 Medicare Program; Medicare Coverage of Screening Pap
Smears for Early Detection of Cervical Cancer.
12/13/93 (58 FR 65150)................ 413 Medicare Program; Reporting of Interest From Zero Coupon
Bonds.
12/14/93 (58 FR 65312)................ 435, 436, Medicaid Program; Extended Medicaid for Certain Families
440, 447 Who Lose AFDC Eligibility Because of Earned Income; Work
Supplementation Participants; Residency of Minor Parents
and Pregnant Individuals.
12/27/93 (58 FR 68366)................ 417 Medicare Program; Retroactive Enrollment and Disenrollment
in Risk Health Maintenance Organizations and Competitive
Medical Plans.
12/29/93 (58 FR 68829)................ 410, 417, Medicare Program; Medicare Coverage and Payment of
424 Clinical Psychologist, Other Psychologist, and Clinical
Social Worker Services.
----------------------------------------------------------------------------------------------------------------
Notices
------------------------------------------------------------------------
Publication date/citation
Title
------------------------------------------------------------------------
10/01/93 (58 FR 51355)... Medicare Program; Payment for Extracorporeal
Shock Wave Lithotripsy Services Furnished by
Ambulatory Surgical Centers.
10/04/93 (58 FR 51632)... HMOs; Exclusion of Gamete Intrafallopian
Transfer and Zygote Intrafallopian Transfer
as Basic Health Services
10/05/93 (58 FR 51827)... Medicare Program; Data, Standards and
Methodology Used to Establish Fiscal Year
1994 Budgets for Fiscal Intermediaries and
Carriers.
10/05/93 (58 FR 51833)... HMOs; Qualification Determinations and
Compliance Actions During the Period April
1, 1993, through June 30, 1993.
10/06/93 (58 FR 52112)... Medicare, Medicaid, and CLIA Programs;
Clinical Laboratory Improvement Amendments
of 1988 Licensed by the State of Washington.
11/02/93 (58 FR 58553)... Medicare Programs; Inpatient Hospital
Deductible and Hospital and Extended Care
Services Coinsurance Amounts for 1994.
11/02/93 (58 FR 58555)... Medicare Program; Part A Premium for 1994 for
the Uninsured Aged and for Certain Disabled
Individuals Who Have Exhausted Other
Entitlement.
11/08/93 (58 FR 59271)... Medicare Program; Monthly Actuarial Rates and
Monthly Supplementary Medical Insurance
Premium Rates Beginning January 1, 1994.
11/16/93 (58 FR 60458)... Medicare Program; Withdrawal of the Provider
Reimbursement Review Board Hearing Manual.
11/22/93 (58 FR 61692)... Medicaid Program; Revised Medicaid Management
Information Systems (MMIS) Functional
Requirements.
11/24/93 (58 FR 62128)... Medicare Program; Payment for Extracorporeal
Shock Wave Lithotripsy Services Furnished by
Ambulatory Surgical Centers (extension of
comment period).
11/26/93 (58 FR 62357)... Medicare Program; Meeting of the Practicing
Physicians Advisory Council.
12/02/93 (58 FR 63856)... Physician Performance Standard Rates of
Increase for Federal Fiscal Year 1994 and
Physician Fee Schedule Update for Calendar
Year 1994.
12/13/93 (58 FR 65186)... Medicare Program; Peer Review Organization,
General Criteria and Standards for
Evaluating Performance of Contract
Obligations.
12/14/93 (58 FR 65357)... Medicare Program; Proposed Additions to and
Deletions From the Current List of Covered
Procedures for Ambulatory Surgical Centers.
12/21/93 (58 FR 67350)... Medicare Program; Changes to the Hospital
Inpatient Prospective Payment Systems and
Fiscal Year 1994 Rates; (Correction).
12/22/93 (58 FR 67796)... Medicare and Medicaid Programs; Quarterly
Listing of Program Issuances and Coverage
Decisions--Third Quarter 1993.
12/23/93 (58 FR 68148)... Approval of the Commission on Office
Laboratory Accreditation.
------------------------------------------------------------------------
Addendum V--Medicare Coverage Issues Manual
(For the reader's convenience, new material and changes to previously
published material are in italics. If any part of a sentence in the
manual instruction has changed, the entire line is shown in italics.
The transmittal includes material unrelated to revised sections. We are
not reprinting the unrelated material.)
Transmittal No. 65; section 65-15, Artificial Hearts and Related
Devices--Not Covered. CHANGED IMPLEMENTING INSTRUCTIONS--EFFECTIVE
DATE; Services Furnished on or After 10/18/93.
Section 65-15, Artificial Hearts and Related Devices, is revised to
provide coverage of the FDA-approved ventricular assist device (known
as the BVS 5000) when used only in patients suffering from
postcardiotomy ventricular dysfunction. The device is intended for
short term use and is not covered when used as a bridge to cardiac
transplantation.
65-15 ARTIFICIAL HEARTS AND RELATED DEVICES--NOT COVERED
There are several devices either in use or under development which
replace all or part of the human heart or assist the heart in
performing its pumping function. Artificial hearts are considered
investigational and not covered under Medicare either when used as a
permanent replacement for a human heart or when used as temporary life-
support systems (i.e., until a human heart becomes available for
transplant).
The FDA-approved ventricular assist device (known as the BVS 5000)
is covered when it is used in accordance with its FDA-approved labeled
uses for postcardiotomy ventricular dysfunction. The device is intended
for short term use and is not covered when used as a bridge to cardiac
transplantation. Other ventricular assist devices used as temporary
life-support systems are still considered investigational and not
covered under the Medicare program. Transmittal No. 66; section 60-4.B,
Medical Documentation. CHANGED PROCEDURES--EFFECTIVE DATE: Services
furnished on or after 01/01/9.
Section 60-4.B, Medical Documentation, is revised to reflect
changes mandated by Sec. 4152 of OBRA 1990, effective for services
rendered on or after January 1, 1991. Implementing changes were
published in the Medicare Carriers Manual in July 1991 (transmittal
1399). Transmittal No. 66; section 60-4.C, Laboratory Evidence. CHANGED
PROCEDURES--EFFECTIVE DATE: 10/27/93.
Section 60-4.C, Laboratory Evidence, is revised to indicate that in
situations where the arterial blood gas and the oximetry studies are
both used to document the need for oxygen therapy and the results are
conflicting, the arterial blood gas study is the preferred service of
documenting medical need because the results of such studies are
considered the best evidence of hypoxemia. In addition, these
instructions also clarify that the prohibition against the use of
results of tests performed by a durable medical equipment (DME)
supplier to qualify patients for home oxygen service does not extend to
the results of an arterial blood gas text by a hospital certified to
conduct such tests.
60-4 HOME USE OF OXYGEN
B. Medical Documentation.--Initial claims for oxygen services must
include a completed Form HCFA-484 (Attending Physician's Certification
of Medical Necessity for Home Oxygen Therapy) to establish whether
coverage criteria are met and to ensure that the oxygen services
provided are consistent with the physician's prescription or other
medical documentation. The attending physician's prescription or other
medical documentation must indicate that the other forms of treatment
(e.g., medical and physical therapy directed at secretions,
bronchospasm and infection) have been tried, have not been sufficiently
successful, and oxygen therapy is still required. While there is no
substitute for oxygen therapy, each patient must receive optimum
therapy before long-term home oxygen therapy is ordered. Use Form HCFA-
484 for recertifications. (See Medicare Carriers Manual Sec. 3312 for
completion of Form HCFA-484.)
The medical and prescription information on Form HCFA-484 can be
completed only by the attending physician or entered on the form from
information in the patient's records by an employee of the physician
for the physician's review and signature. Although hospital discharge
coordinators, nurses, and medical social workers may assist in
arranging for physician-prescribed home oxygen, they have no authority
to prescribe the services or to enter medical or prescription
information in items 1 through 6 of Form HCFA-484. Suppliers may not
enter this information either.
Unlike other types of DME, a physician's certification of medical
necessity for oxygen equipment must include the results of specific
testing before coverage can be determined.
Initial claims for oxygen must also be supported by medical
documentation. Separate documentation is used with electronic billing.
(See Medicare Carriers Manual, Part 3, Sec. 4105.6.) This documentation
may be in the form of a prescription written by the patient's attending
physician who has recently examined the patient (normally within a
month of the start of therapy) and must specify:
A diagnosis of the disease requiring home use of oxygen;
The oxygen flow rate; and
An estimate of the frequency, duration of use (e.g., 2
liters per minute, 10 minutes per hour, 12 hours per day), and duration
of need (e.g., 6 months or lifetime).
Note: A prescription for ``Oxygen PRN'' or ``Oxygen as needed''
does not meet this last requirement. Neither provides any basis for
determining if the amount of oxygen is reasonable and necessary for
the patient.
All claims with oxygen flow rates of more than 2 liters per minute
must be reviewed by a carrier's medical staff before payment can be
made. The attending physician may also specify the type of oxygen
delivery system to be used (i.e., gas, liquid, or concentrator). If the
type of system is specified, then the medical reasons for selecting
that system over the alternative systems must also be specified.
New medical documentation written by the patient's attending
physician must be submitted to the carrier in support of revised oxygen
requirements when there has been a change in the patient's condition
and need for oxygen therapy.
Carriers are required to conduct periodic, continuing medical
necessity reviews on patients whose conditions warrant these reviews
and on patients with indefinite or extended periods of necessity as
described in Medicare Carriers Manual, Part 3, Sec. 4105.6.C. When
indicated, carriers may also request documentation of the results of a
repeat arterial blood gas or oximetry study.
Note: Section 4152 of OBRA 1990 requires earlier recertification
and retesting of oxygen patients who begin coverage with an arterial
blood gas result at or above a partial pressure of 55 or an arterial
oxygen saturation percentage at or above 89. (See Medicare Carriers
Manual Sec. 4105.6 for certifications and retesting schedules.)
C. Laboratory Evidence.--Initial claims for oxygen therapy must
also include the results of a blood gas study that has been ordered and
evaluated by the attending physician. This is usually in the form of a
measurement of the partial pressure of oxygen (PO2) in arterial blood.
(See Medicare Carriers Manual, Part 3, Sec. 2070.1 for instructions on
clinical laboratory tests.) A measurement of arterial oxygen saturation
obtained by ear or pulse oximetry, however, is also acceptable when
ordered and evaluated by the attending physician and performed under
his or her supervision or when performed by a qualified provider or
supplier of laboratory services. In situations when the arterial blood
gas and the oximetry studies are both used to document the need for
home oxygen therapy and the results are conflicting, the arterial blood
gas study is the preferred source of documenting medical need. A DME
supplier is not considered a qualified provider or supplier of
laboratory services for purposes of these guidelines. This prohibition
does not extend to the results of an arterial blood gas test conducted
by a hospital certified to do such tests. The conditions under which
the laboratory tests are performed must be specified in writing and
submitted with the initial claim, i.e., at rest, while sleeping, while
exercising, on room air, or if while on oxygen, the amount, body
position during testing, and similar information necessary for
interpreting the evidence as specified by the carrier.
The preferred sources of laboratory evidence are existing physician
and/or hospital records that reflect the patient's medical condition.
Since it is expected that virtually all patients who qualify for home
oxygen coverage for the first time under these guidelines have recently
been discharged from a hospital where they submitted to arterial blood
gas tests, the carrier needs to request that such test results be
submitted in support of their initial claims for home oxygen. If more
than one arterial blood gas test is performed during the patient's
hospital stay, the test result obtained closest to the hospital
discharge date is the best evidence of the need for home oxygen
therapy.
Carriers may accept an attending physician's statement of recent
hospital test results for a particular patient, when appropriate, in
lieu of copies of actual hospital records. Subsequent blood gas tests
that appear to duplicate the hospital test (e.g., when there is no
reason to believe the patient's condition may have changed) are denied
as not medically reasonable and necessary.
A repeat arterial blood gas or oximetry study is normally necessary
only when evidence indicates that an oxygen recipient has undergone a
major change relevant to home use of oxygen. For example, if the
carrier has reason to believe that there has been a major change in the
patient's physical condition (e.g., when there has been a significant
increase in the amount of oxygen billed on a monthly basis), it may ask
for documentation of the results of another blood gas or oximetry
study.
[FR Doc. 94-6153 Filed 3-16-94; 8:45 am]
BILLING CODE 4120-01-P
