Medicare and Medicaid Programs; Quarterly Listing of Program Issuances and Coverage DecisionsThird Quarter 1994
Federal RegisterJan 3, 1995
Ask Donna
What actually matters in this document.
Text
DEPARTMENT OF HEALTH AND HUMAN SERVICES
[BPO-129-N]
Medicare and Medicaid Programs; Quarterly Listing of Program
Issuances and Coverage Decisions--Third Quarter 1994
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 July, August, and
September of 1994 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 July 1 and September 30, 1994.
On August 21, 1989, we published the content of the Manual (54 FR
34555) 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) 966-5255 (For Medicare instruction information)
Walter Rutemueller, (410) 966-5395 (For Medicare coverage information)
Pat Prete, (410) 966-3246 (For Medicaid instruction information)
Michael Robinson, (410) 966-5633 (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, l871, 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 [[Page 133]] 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
July 1 through September 30, 1994.
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 (54 FR 34555).
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 September 30,
1994. 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, the Parts of the Code of Federal Regulations (CFR)
which have changed (if applicable), the agency file code number, the
ending date of the comment period (if applicable), and the effective
date (if applicable).
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, U.S. 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. [[Page 134]]
HCFA program memoranda.
The titles of the Compilation of the Social Security Laws are current
as of January 1, 1993. The remaining portions of CD-ROM are updated on
a monthly basis.
The CD-ROM disk does not contain Appendix M (Interpretative
Guidelines for Hospices). Copies of this appendix 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 3--Claims Process (HCFA-Pub. 13-3)
transmittal entitled ``Essential Access Community Hospital and Rural
Primary Care Hospital'', use the Superintendent of Documents No. HE
22.8/6, and the HCFA transmittal number 1626.
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, Issuances Staff, 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) 966-3246.
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
Michael Robinson, Office of Regulations, Health Care Financing
Administration, Room 132 East High Rise, 6325 Security Blvd.,
Baltimore, MD 21207, Telephone (410) 966-5633.
(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: December 19, 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)
March 17, 1994 (59 FR 12610)
August 5, 1994 (59 FR 40038)
November 14, 1994 (59 FR 56501)
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.
Medicare End Stage Renal Disease; Network Organizations Manual
This manual presents technical instructions and/or changes in
procedures that pertain to ESRD network organizations in an
understandable format, which can be easily modified. This manual
benefits both HCFA and its customers.
Addendum III.--Medicare and Medicaid Manual Instructions July through September 1994
----------------------------------------------------------------------------------------------------------------
Trans. No. Manual/Subject/Publication No.
----------------------------------------------------------------------------------------------------------------
Intermediary Manual Part 2--Audits, Reimbursement Program Administration (HCFA-Pub. 13-2) (Superintendent of
Documents No. HE 22.8/6-1)
----------------------------------------------------------------------------------------------------------------
398 <bu Beneficiary Services.
l
Provider Services.
399 <bu Quarterly Periodic Interim Payment Report.
l
----------------------------------------------------------------------------------------------------------------
Intermediary Manual Part 3--Claims Process (HCFA-Pub. 13-3) (Superintendent of Documents No. HE 22.8/6)
----------------------------------------------------------------------------------------------------------------
1626 <bu Essential Access Community Hospital and Rural Primary Care Hospital.
l
Criteria and Payment for Essential Access Community Hospital and Rural Primary Care Hospital.
Review of Form HCFA-1450 for Inpatient and Outpatient Bills for Rural Primary Care Hospitals.
1627 <bu Monthly Intermediary Workload Report. (Form HCFA-1566)--General.
l
Completing Page One of the Monthly Intermediary Workload Report.
[[Page 135]]
Checking Reports.
Body of Report.
1628 <bu Payment for Blood Clotting Factor Administered to Hemophilia Inpatients.
l
Reporting Outpatient Services Using HCFA Common Procedure Coding System.
HCPCS Codes for Diagnostic Services and Medical Services.
Ambulance Services.
1629 <bu Surgical Dressings, and Splints, Casts, and Other Devices Used for Reduction of Fractures and
l Dislocations.
1630 <bu Requirements for Submission of EMC Data.
l
File Specifications, Records Specifications, and Data Element Definitions for EMC Bills.
National Standard Electronic Remittance Advice.
Medicare Standard Electronic PC-Print Software.
1631 <bu Medical Review Guidelines for Review of Observation and Assessment and Management and
l Evaluation in Skilled Nursing Facilities.
1632 <bu Reporting Outpatient Surgery and Other Services.
l
1633 <bu HCPCS for Hospital Outpatient Radiology Services and Other Diagnostic Procedures.
l
1634 <bu Epoetin.
l
1635 <bu Medical Review of Home Health Services.
l
HCFA-485--Home Health Certificate and Plan of Care Data Elements.
HCFA-486--Medical Update and Patient Information.
----------------------------------------------------------------------------------------------------------------
Carrier Manual Part 3--Claims Process (HCFA-14-3) (Superintendent of Documents No. HE 22.8/7)
----------------------------------------------------------------------------------------------------------------
1489 <bu Completion of Items on Page One of Form HCFA-1565.
l
Part D(2)--Claims Processing Timeliness--EMC Claims and Adjustments for CPEP CPT
Calculations.
Checking Reports Prior to Submittal to HCFA.
1490 <bu Epoetin.
l
1491 <bu Billing for Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services.
l
Billing for SNF and NF Visits.
1492 <bu Technical Specifications of the EOMB and Exhibits.
l
1493 <bu Type of Service.
l
1494 <bu Coding Physician Specialty.
l
Coding Type of Supplier and Nonphysician Provider.
Coding Types of Service for Group Practice Prepayment Plan.
Description of Entry Code.
1495 <bu Therapeutic Shoes for Individuals With Diabetes.
l
1496 <bu Ambulatory Surgical Center Code.
l
1497 <bu Medical Review.
l
Coordination With Carrier Medicare Fraud Unit.
Development of MR Policy--General.
National Coverage Policy.
Local MR Policy.
Internal MR Guidelines.
The Carrier Advisory Committee.
Data Analyses to Focus MR.
Aberrancies.
Taking Corrective Actions on Identified Aberrancies.
Conducting Evaluation of Effectiveness of Corrective Action.
Standard Postpayment Data Reports.
Medicare FMR Status Report.
Provider Tracking System.
Prepayment Review Procedures.
Prepayment MR and Audit Trail.
MR Prepayment Screens.
Evaluation of MR Prepayment Screens.
Categories of MR Screens.
MR Screen Parameters.
Developing Cases for Additional Medical Necessity Documentation.
HCFA Mandated and HCFA Optional MN Screens.
Prepayment Review Personnel and Procedures Levels of Manual Review.
Postpayment MR.
Postpayment Review Personnel.
Provider Audit List.
Comprehensive Medical Review Requirements.
CMR Case Selection.
Conducting the CMR.
CMR Corrective Actions.
Overpayment Assessment.
Definition of Overpayment Assessment Terms.
Assessing an Overpayment When the CMR Was Based on a Statistically Valid Random Sample.
Assessing on Overpayment or a Potential Overpayment When the CMR Was Based on a Limited
Sample/Subsample.
Comparative Performance Report Requirements.
MR Denials.
[[Page 136]]
Section 1879 Determination.
Section 1870 Determination.
Section 1842(l) Determination.
Appeal of MR Denials.
The Carrier Medical Director.
1498 <bu Foot Care and Supportive Devices for Feet.
l
1499 <bu Data Sets and Formats for Electronic Media Claims and Electronic Remittance Advice.
l
Medicare Standard PC-Print-B Software.
1500 <bu Epoetin.
l
----------------------------------------------------------------------------------------------------------------
Program Memorandum Intermediaries (HCFA-Pub. 60A) (Superintendent of Documents No. HE 22.8/6-5)
----------------------------------------------------------------------------------------------------------------
A-94-5 <bu Letter to Participating Hospitals Regarding Physician Acknowledgment Statements Under the
l Physician Attestation Requirement.
A-94-6 <bu Medicare Payment for Extracorporeal Photopheresis Performed in Hospital Outpatient Setting.
l
A-94-7 <bu Hospital Outpatient Procedures: Update to List of Radiology Procedures and Other Diagnostic
l Services Subject to the Payment Limit and Update to the List of HCPCS Codes to Be Grossed-
Up.
----------------------------------------------------------------------------------------------------------------
Program Memorandum Carrier (HCFA-Pub. 60B) (Superintendent of Documents No. HE 22.8/6-5)
----------------------------------------------------------------------------------------------------------------
B-94-4 <bu Suspension of Beneficiary Address Overlay Process.
l
B-94-5 <bu Beneficiary Address Overlay.
l
----------------------------------------------------------------------------------------------------------------
Program Memorandum Intermediaries/Carriers (HCFA-Pub. 60 A/B) (Superintendent of Documents No. HE 22.8/6-5)
----------------------------------------------------------------------------------------------------------------
AB-94-4 <bu Current Status of Medicare Program Memorandums and Letters Issued Before.
l
AB-94-5 <bu Coverage of Oral Cancer Drugs and Uniform Coverage of Off-Label Uses of Anti-Cancer Drugs
l Provided for by Omnibus Budget Reconciliation Act of 1993.
AB-94-6 <bu HCPCS Codes for Ambulance Services Furnished to Beneficiaries With End Stage Renal Disease
l and For Scheduled Transports.
----------------------------------------------------------------------------------------------------------------
Program Memorandum Regional Offices General (HCFA-Pub. 51) (Superintendent of Documents No. HE 22.8/6-5)
----------------------------------------------------------------------------------------------------------------
94-2 <bu Bed-Hold Policies for Long Term Care Facilities.
l
----------------------------------------------------------------------------------------------------------------
Program Memorandum Medicaid State Agencies (HCFA-Pub. 17) (Superintendent of Documents No. HE 22.8/6-5)
----------------------------------------------------------------------------------------------------------------
94-6 <bu Current Status of Medicaid Program Memorandum and Action Transmittals Issued Before Calendar
l Year 1994.
94-7 <bu Title XIX, Social Security Act, Tuberculosis-Related Services.
l
----------------------------------------------------------------------------------------------------------------
Program Memorandum Insurance Commissioners (HCFA-Pub. 80) (Superintendent of Documents No. HE 22.28/5:90-1)
----------------------------------------------------------------------------------------------------------------
94-2 <bu Medigap Bulletin Series (Number Two).
l
----------------------------------------------------------------------------------------------------------------
Regional Office Manual Medicare (HCFA-Pub. 23-2) (Superintendent of Documents No. HE 22.28/5:90-1)
----------------------------------------------------------------------------------------------------------------
327 <bu The Contractor Performance Evaluation Program.
l
CPEP Principles.
Scheduling Reviews.
CPEP Review Completion Dates.
Sampling Methodology.
Sampling Techniques.
Sample Size Chart.
Methodology For Determining Whether Performance Requirements Are Met.
Determinations through Sampling.
Documentation of CPEP Reviews.
Program Requirements Criterion CPEP Review Report.
CPEP Review Report.
Process Improvement Criterion Documentation.
Retention of Documentation.
Notifying Contractors of CPEP Evaluation Results.
Process Improvement Criterion.
Appeals.
Appeals Rights.
Processing Appeals.
Reporting Final Determination.
Corrective Action Plan.
When CAPs are Required.
The Content of the CAP.
CPEP Evaluation of Multi-State and Multi-Regional Contractors.
Determining When Separate CPEPs are Needed.
[[Page 137]]
Definitions of Multi-Regional and Multi-State Contractors.
Principles of Evaluation of Multi-State Contractors and Multi-Regional Contractor FOs.
Separate Evaluation of the Program Requirements Criterion CPEP Standards.
Separate Evaluation of the Process Improvement Criterion of CPEP.
Evaluation of Financial Standards.
Sampling for Multi-State Contractors.
Reporting Requirements for Multi-State Contractors.
Contract Management Actions.
----------------------------------------------------------------------------------------------------------------
Peer Review Organization Manual (HCFA-Pub. 19) (Superintendent of Documents No. HE 22.8/15)
----------------------------------------------------------------------------------------------------------------
38 <bu Background.
l
Confidentiality Requirements.
Report Requirements.
Publication Requirements.
Distribution Requirements.
Introduction.
Requirements.
Qualifications.
Additional Clinical Coordinators.
Responsibilities.
Cooperative Project Development and Implementation.
39 <bu Hearings by an ALJ.
l
Appointment of Representative.
Foreword, Statutory/Regulatory References.
Notification of Quality Concerns to Affected Parties.
Confidential Information.
----------------------------------------------------------------------------------------------------------------
Hospital Manual (HCFA-Pub. 10) (Superintendent of Documents No. HE 22.8/2)
----------------------------------------------------------------------------------------------------------------
667 <bu PRO Monitoring of Hospital Notices for Denial of Continued Stay of Inpatient Care Under PPS.
l
Issuance of Notices of Noncoverage.
Content of Hospital-Issued Notices of Noncoverage.
PRO Monitoring of HINNs.
Notices in Investigational/Experimental Procedures Situations.
Beneficiary Liability.
Provider Liability.
Right to a Reconsideration.
668 <bu Surgical Dressing, and Splints, Casts, and Other Devices Used for Reduction of Fractures and
l Dislocations.
669 <bu Data Elements on the UB-2.
l
Oral Cancer Drugs.
Billing for Clinical Diagnostic Laboratory Services Other Than To Inpatients.
Reporting Outpatient Surgery and Other Services.
Billing for Durable Medical Equipment and Orthotic/Prosthetic Devices.
Payment for Blood Clotting Factor Administered to Hemophilia Inpatients.
Payment for Epoetin.
670 <bu HCPCS for Hospital Outpatient Radiology Services and Other Diagnostic Procedures.
l
671 <bu Reporting Outpatient Surgery and Other Services.
l
Reporting Outpatient Surgery and Other Services.
672 <bu Epoetin.
l
----------------------------------------------------------------------------------------------------------------
Christian Science Sanatorium Hospital Manual Supplement (HCFA-Pub. 32) (Superintendent of Documents No. HE 22.8/
2-2)
----------------------------------------------------------------------------------------------------------------
33 <bu Billing Procedures--General.
l
Billing Procedures Applicable to Periodic Interim Payment Method of Payment for Hospitals and
SNFs.
Inpatient Admission and Billing Christian Science Sanatorium (Form HCFA-1450).
Completion of Form HCFA-1450 For Inpatient Christian Science Sanatorium Services or Christian
Science Sanatorium Services.
Claims Processing Timeliness.
----------------------------------------------------------------------------------------------------------------
Skilled Nursing Facility (HCFA-Pub. 12) (Superintendent of Documents No. HE 22.8/3)
----------------------------------------------------------------------------------------------------------------
330 <bu Surgical Dressings, and Splints, Casts, and Other Devices Used for Reduction of Fractures and
l Dislocations.
331 <bu Completion of Form HCFA-1450 for Inpatient and/or Outpatient Billing.
l
Provider Electronic Billing File and Record Formats.
Alphabetic Listing of Data Elements.
----------------------------------------------------------------------------------------------------------------
Health Maintenance Organization/Competitive Medical Plan Manual (HCFA-75) (Superintendent of Documents No. HE
22.8/21:989)
----------------------------------------------------------------------------------------------------------------
13 <bu Effect of Change Without Novation Agreement.
l
Submittal of Novation Agreement.
[[Page 138]]
Conditions for HCFA Approval of Novation Agreement.
Leasing of HMO/CMP Facilities.
Model Novation Agreement.
----------------------------------------------------------------------------------------------------------------
State Medicaid Manual Part 3--Eligibility (HCFA-Pub. 45-3) (Superintendent of Documents No. HE 22.8/10)
----------------------------------------------------------------------------------------------------------------
63 <bu Medicaid Estate Recoveries.
l
----------------------------------------------------------------------------------------------------------------
Coverage Issues Manual (HCFA-Pub. 6) (Superintendent of Documents No. HE 22.8/14)
----------------------------------------------------------------------------------------------------------------
71 <bu Outpatient Diabetic Education Programs.
l
----------------------------------------------------------------------------------------------------------------
Provider Reimbursement Manual Part 1--(HCFA-Pub. 15-1) (Superintendent of Documents No. HE 22.8/4)
----------------------------------------------------------------------------------------------------------------
378 <bu Inpatient Routine Service Cost Limits for Skilled Nursing Facilities.
l
Provider Requests Regarding Applicability of Cost Limits.
Request for Exception to SNF Cost Limits.
Adjustment of Interim Rate.
Operational Review.
Formal Appeal of Determinations on Requests for Reclassification, Exceptions, and Exemptions.
379 <bu Non-PPS Hospitals and Distinct Part Units.
l
Hospitals and Distinct Part Units of Hospitals Subject to Rate of Increase Ceiling on
Inpatient Operating Costs.
Calculating Rate of Increase Ceiling on Hospital Inpatient Operating Costs.
Exemptions From Rate of Increase Ceiling.
Adjustments to Rate of Increase Ceiling Assignment of New Base Period.
Appeal Rights.
----------------------------------------------------------------------------------------------------------------
Provider Reimbursement Manual Part II--Provider Cost Reporting Forms and Instructions (HCFA-Pub. 15-IIAC)
(Chapter 29) (Superintendent of Documents No. HE 22.8/4)
----------------------------------------------------------------------------------------------------------------
2 <bu Worksheet C--Determination of Medicare Payment.
l
Supplemental Worksheet B-1--Calculation of Pneumococcal and Influenza Vaccine Cost.
3 <bu Rounding Standards for Fractional Computations.
l
----------------------------------------------------------------------------------------------------------------
Provider Reimbursement Manual Part II--Provider Cost Reporting Forms and Instructions (HCFA-Pub. 15-IIAB)
(Chapter 28) (Superintendent of Documents No. HE 22.8/4)
----------------------------------------------------------------------------------------------------------------
5 <bu General.
l
Acronyms and Abbreviations.
Worksheet S-2--Hospital and Hospital Health Care Complex Identification Data.
Worksheet C, Parts III-V.
Supplemental Worksheets M-1--M-4 Electronic Reporting Specifications for Form HCFA-2552-92.
----------------------------------------------------------------------------------------------------------------
Provider Reimbursement Manual Part II--Provider Cost Reporting Forms and Instructions (HCFA-Pub. 15-IIX)
(Chapter 24) (Superintendent of Documents No. HE 22.8/4)
----------------------------------------------------------------------------------------------------------------
6 <bu Updated Graduate Medical Education Adjustment Factors for the 1989 Cost Reports.
l
----------------------------------------------------------------------------------------------------------------
Renal Dialysis Facility Manual (Non-Hospital Operated) (HCFA-Pub. 29) (Superintendent of Documents No. HE 22.8/
13)
----------------------------------------------------------------------------------------------------------------
69 <bu Surgical Dressings, and Splints, Casts, and Other Devices Used for Reductions of Fractures
l and Dislocations.
70 <bu Epoetin.
l
----------------------------------------------------------------------------------------------------------------
Home Health Agency Manual (HCFA-Pub. 11) (Superintendent of Documents No. HE 22.8/5)
----------------------------------------------------------------------------------------------------------------
270 <bu Billing for Oral Cancer Drugs.
l
271 <bu Surgical Dressings, and Splints, Casts, and Other Devices Used for Reduction of Fractures and
l Dislocations.
272 <bu Data Elements Needed to Render a Home Health Coverage Determination.
l
HCFA-485 Home Health Certificate and Plan of Care.
HCFA-486 Medical Update and Patient Information.
----------------------------------------------------------------------------------------------------------------
Health Maintenance Organization/Competitive Medical Plan Manual (HCFA-Pub. 75) (Superintendent of Documents No.
HE 22.8/21:989)
----------------------------------------------------------------------------------------------------------------
13 <bu Effect of Change Without Novation Agreement.
l
Submittal of Novation Agreement.
Conditions for HCFA Approval of Novation Agreement.
Leasing of HMO/CMP Facilities.
Model Novation Agreement.
----------------------------------------------------------------------------------------------------------------
[[Page 139]]
End Stage Renal Disease Network Organizations Manual (HCFA-Pub. 81) (Superintendent of Documents No. )
----------------------------------------------------------------------------------------------------------------
1 <bu Authority.
l
Purpose of Networks.
Network Responsibilities.
Health Care Financing Administration's Role.
----------------------------------------------------------------------------------------------------------------
Medicare/Medicaid Sanction--Reinstatement Report
----------------------------------------------------------------------------------------------------------------
94-7 <bu Report of Physicians/Practitioners, Providers and/or Other Health Care Suppliers.
l
94-8 <bu Report of Physicians/Practitioners, Providers and/or Other Health Care Suppliers.
l
94-9 <bu Report of Physicians/Practitioners, Providers and/or Other Health Care Suppliers Excluded/
l Reinstated.
94-10 <bu Cumulative Report of Physician/Practitioners, Providers and/or Other Health Care Suppliers
l Excluded/Reinstated.
94-11 <bu Report of Physicians/Practitioners, Providers and/or Other Health Care Suppliers Excluded/
l Reinstated.
----------------------------------------------------------------------------------------------------------------
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End of
Publication date Vol. 50 FR page CFR part File code* Regulation title comment Effective
numbers period date
--------------------------------------------------------------------------------------------------------------------------------------------------------
07/13/94............ 35664 421................. BPO-111-N Medicare Program; Intermediary and Carrier 10/11/94 ...........
Functions.
07/14/94............ 35933-35935 .................... BPO-116-FN Medicare Program; Data, Standards, and 07/14/94
Methodology Used To Establish Fiscal Year
1994 Budgets for Fiscal Intermediaries
and Carriers.
07/14/94............ 35935-35936 .................... BPD-799-GN Medicare Program; Medicare Secondary Payer ........... 08/15/94
(MSP) Amendments.
07/15/94............ 36069-36071 405, 414............ BPD-770-CN Medicare Program; Revisions to Payment ........... 01/01/94
Policies and Adjustments to the Relative
Value Units Under the Physician Fee
Schedule for Calendar Year 1994
(CORRECTION TO A FINAL RULE).
07/15/94............ 36072-36087 417, 431, 434, 1003. RIN0991-AA44 Medicare and State Health Care Programs; ........... 09/13/94
Fraud and Abuse, Civil Money Penalties
and Intermediate Sanctions for Certain
Violations by Health Maintenance
Organizations and Competitive Medical
Plans.
07/18/94............ 36415-36418 421................. BPO-105-P Medicare Program; Part B Advance Payments 9/16/94 ...........
to Suppliers Furnishing Items or Services
under Medicare Part B.
07/18/94............ 36419-36421 440................. MB-085-P Medicaid Program; Nurse-Midwife Services.. 9/16/94 ...........
07/19/94............ 36707-36713 412, 413, 418....... BPD-436-F Medicare Program; Periodic Interim ........... 08/18/94
Payments for Hospitals and Other
Providers.
07/25/94............ 37702-37720 435, 440, 441....... MB-008-FC Medicaid Program; Home and Community-Based 09/23/94 08/24/94
Services and Respiratory Care for
Ventilator-Dependent Individuals.
08/02/94............ 39296-39298 400................. OFH-017-FC Medicare and Medicaid Programs; Approved 10/03/94 08/02/94
Information Collection Requirements.
08/04/94............ 39828-39830 405, 414............ BPD-770-CN Medicare Program; Revisions to Payment ........... 07/15/94
Policies and Adjustments to the Relative
Value Units Under the Physician Fee
Schedule for Calendar Year 1994 (OFR
CORRECTION TO A FINAL RULE).
08/05/94............ 40037-40038 .................... OMC-020-N Health Maintenance Organizations; ........... ...........
Qualification Determinations During the
Period January 1, 1994 through March 31,
1994.
08/05/94............ 40038-40048 .................... BPO-126-N Medicare and Medicaid Programs; Quarterly ........... ...........
Listing of Program Issuances and Coverage
Decisions-First Quarter 1994.
08/22/94............ 43050-43053 435, 436............ MB-001-F Medicaid Program; Eligibility and Coverage ........... 08/18/94
Requirements.
[[Page 140]]
08/26/94............ 44097-44109 412, 413, 414....... BPD-763-P Medicare Program; End Stage Renal Disease 10/25/94 ...........
(ESRD) Payment Exception Requests and
Organ Procurement Costs.
08/26/94............ 44151-44152 .................... OPL-001-N Medicare Program; Meeting of the ........... ...........
Practicing Physicians Advisory Council.
09/01/94............ 45330-45524 412, 413, 466, 482, BPD-802-FC Medicare Program; Changes to the Hospital 10/31/94 10/01/94
485, 489. Inpatient Prospective Payment Systems and
Fiscal Year 1995 Rates.
09/06/94............ 46056-46057 .................... BPO-117-GN Medicare Program; Criteria and Standards ........... 09/06/94
for Evaluating Intermediary and Carrier
Performance During FY 1994.
09/07/94............ 46258-46263 .................... BPO-123-GNC Medicare Program; Criteria and Standards 10/07/94 10/01/94
for Evaluating Intermediary and Carrier
Performance During FY 1995.
09/08/94............ 46500-46517 405, 482, 485....... BPD-646-IFC Medicare and Medicaid Programs; Conditions 11/07/94 10/11/94
of Coverage for Organ Procurement
Organizations.
09/23/94............ 48805-48811 435, 436............ MB-052-IFC Medicaid Program; Outstation Intake 11/22/94 10/24/94
Locations for Certain Low-Income Pregnant
Women, Infants, and Children Under Age 19.
09/23/94............ 48811-48825 456................. MB-050-F Medicaid Program; Drug Use Review Program ........... 10/24/94
and Electronic Claims Management System
for Outpatient Drug Claims.
09/27/94............ 49249-49251 .................... ORD-069-N Medicaid Program; Demonstration Proposals ........... ...........
Pursuant to Section 1115(a) of the Social
Security Act; Policies and Procedures.
09/30/94............ 49826-49834 405, 410, 411, 413, BPD-724-F Medicare Program; Medicare Coverage of ........... 10/01/94
494. Screening Mammography.
09/30/94............ 49834-49843 417................. OMC-009-FC Medicare Program; Qualified Health 11/29/94 10/31/94
Maintenance Organizations: Technical
Amendments.
--------------------------------------------------------------------------------------------------------------------------------------------------------
*GN--General Notice; PN--Proposed Notice; FN--Final Notice; P--Proposed Rule; F--Final Rule; FC--Final Rule with Comment Period; CN--Correction Notice;
N--Suspension Notice; WN--Withdrawal Notice; NR--Notice of HCFA Ruling; IFC--Interim Final Rule with Comment Period.
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. 71; section 80-2 Outpatient Diabetic Education
Programs. NEW IMPLEMENTING INSTRUCTIONS--EFFECTIVE DATE: Services
Furnished on or After 09/22/94.
Section 80-2, Outpatient Diabetic Education Programs.-- This
section has been added to reflect coverage of outpatient diabetic
education programs.
80-2 OUTPATIENT DIABETIC EDUCATION PROGRAMS
An outpatient hospital diabetic education program is a program
which educates patients in the successful self-management of
diabetes. An outpatient diabetic program includes education about
performance of frequent self-monitoring of blood glucose, education
about diet and exercise, an insulin treatment plan developed
specifically for the patient who is insulin-dependent, and
motivation to use the skills learned to enable self-management.
Education programs should identify themselves as programs for non-
insulin patients, insulin-dependent patients, or both.
Outpatient hospital diabetic education programs may be covered
under Medicare provided the services are furnished under a
physician's order by the provider's personnel and under medical
staff supervision to individuals who are registered patients of that
provider. The services must be closely related to the care and
treatment of the individual patient and must provide the patient
with essential knowledge that aids in the patient's active
participation in his/her own treatment and the skills that enable
self-management.
Do not substitute formally structured education programs for the
more traditional and generally effective instruction included as a
part of the basic care and treatment furnished to the patient by the
health care professional.
The overall goal of outpatient hospital diabetic education
programs is self-management of the disease, and each program must be
sufficiently flexible to meet the individual needs of the patient.
(This does not preclude some sessions of the programs to be given on
an outpatient group basis.) The individual plan of care must
indicate at a minimum the goals for the individual patient and how
these goals will be realized.
Not all diabetic patients are eligible to participate in these
programs. In general, the kinds of patients that are likely to be
suitable candidates for outpatient education programs are newly
diagnosed diabetics and/or unstable diabetics (e.g., a long-term
diabetic with current management problems).
Entrance into these programs is by physician referral only.
Self-referral is not covered. The duration of these programs should
be sufficient to meet the goals of self-management within the
timeframe indicated in the plan of treatment. It is not expected
that any given patient could be eligible to reenter an education
program unless new conditions warrant it. [[Page 141]]
After the intermediary determines that a program may be covered,
the intermediary may request additional documentation to make a
claims determination.
[FR Doc. 94-32295 Filed 12-30-94; 8:45 am]
BILLING CODE 4120-03-P
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.