[Federal Register Volume 64, Number 135 (Thursday, July 15, 1999)]
[Notices]
[Pages 38203-38204]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-18008]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[Document Identifier: HCFA-484]
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
In compliance with the requirement of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the Health Care Financing
Administration (HCFA), Department of Health and Human Services, has
submitted to the Office of Management and Budget (OMB) The following
proposal for the collection of information. Interested persons are
invited to send comments regarding the burden estimate or any other
aspect of this collection of information, including any of the
following subjects: (1) The necessity and utility of the proposed
information collection for the proper performance of the agency's
functions; (2) the accuracy of the estimated burden; (3) ways to
enhance the quality, utility, and clarity of the information to be
collected; and (4) the use of automated collection techniques or other
forms of information technology to minimize the information collection
burden.
Type of Information Collection Request: Extension of a currently
approved collection;
Title of Information Collection: Attending Physician's
Certification of Medical Necessity for Home Oxygen Therapy and
Supporting Regulations in 42 CFR 410.38 and 424.5;
Form No.: HCFA-484 (OMB# 0938-0534);
Use: To determine if oxygen is reasonable and necessary pursuant to
Medicare Statute, Medicare claims for home oxygen therapy must be
supported by the treating physician's statement and other information
including estimate length of need (# of months), diagnosis codes (ICD-
9) and:
1. Results and date of the most recent arterial blood gas
PO\2\ and/or oxygen saturation tests.
2. The most recent arterial blood gas PO\2\ and/or
oxygen saturation test performed EITHER with the patient in a chronic
stable state as an outpatient, OR within two days prior to discharge
from an inpatient facility to home.
3. The most recent arterial blood gas PO\2\ and/or
oxygen saturation test performed at rest, during exercise, or during
sleep.
4. Name and address of the physician/provider performing the most
recent arterial blood gas PO\2\ and/or oxygen saturation
test.
5. If ordering portable oxygen, information regarding the patient's
mobility within the home.
6. Identification of the highest oxygen flow rate (in liters per
minute) prescribed.
7. If the prescribed liters per minute (LPM), as identified in item
6, are greater than 4 LPM, provide the results and date of the most
recent arterial blood gas PO\2\ and/or oxygen saturation
test taken on 4 LPM.
If the PO2 = 56-59, or the oxygen saturation = 89%, then
evidence of the beneficiary meeting at least one of the following
criteria must be provided.
8. The patient having dependent edema due to congestive heart
failure.
9. The patient having cor pulmonale or pulmonary hypertension, as
documented by pulmonale on an EKG or by an echocardiogram, gated blood
pool scan or direct pulmonary artery pressure measurement.
10. The patient having a hematocrit greater than 56%.
Form HCFA-484 obtains all pertinent information and promotes
national consistency in coverage determinations.;
Frequency: Other (as needed);
Affected Public: Business or other for-profit, and Federal
Government;
[[Page 38204]]
Number of Respondents: 500,000;
Total Annual Responses: 500,000;
Total Annual Hours: 50,000.
To obtain copies of the supporting statement for the proposed
paperwork collections referenced above, access HCFA's WEB SITE ADDRESS
at http://www.hcfa.gov/regs/prdact95.htm, or E-mail your request,
including your address and phone number, to Paperwork@hcfa.gov, or call
the Reports Clearance Office on (410) 786-1326. Written comments and
recommendations for the proposed information collections must be mailed
within 30 days of this notice directly to the OMB Desk Officer
designated at the following address: OMB Human Resources and Housing
Branch, Attention: Allison Eydt, New Executive Office Building, Room
10235, Washington, DC 20503.
Dated: June 15, 1999.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA, Office of Information Services,
Security and Standards Group, Division of HCFA Enterprise Standards.
[FR Doc. 99-18008 Filed 7-14-99; 8:45 am]
BILLING CODE 4120-03-P
