Medicare and Medicaid Programs; Quarterly Listing of Program Issuances and Coverage DecisionsFirst Quarter 1995

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration

[BPO-131-N]

Medicare and Medicaid Programs; Quarterly Listing of Program

Issuances and Coverage Decisions--First Quarter 1995

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: Notice.

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SUMMARY: This notice lists HCFA manual instructions, substantive and

interpretive regulations and other Federal Register notices, and

statements of policy that were published during January, February, and

March of 1995 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 January 1 and March 31, 1995. 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) 786-5255 (For Medicare instruction information).

Pat Prete, (410) 966-3246 (For Medicaid instruction information). After

July 21, 1995, (410) 786-3246. Nancy Ranels, (410) 966-8928 (For all

other information). After August 4, 1995, (410) 786-8928.

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 38 million Medicare beneficiaries and 36

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

January 1 through March 31, 1995.

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 June 9, 1988 (53 FR 21730),

September 22, 1988 (53 FR 36891), December 16, 1988 (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

[[Page 38345]]

Manual. These updates, when added to material from the manual published

on August 21, 1989 constitute a complete manual as of March 31, 1995.

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 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.

Addendum V 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).

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) 512-

1800, 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 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. 14-3) transmittal entitled ``Medical

Review,'' use the Superintendent of Documents No. HE 22.8/7 and the

HCFA transmittal number 1508.

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, Bureau of Program Operations,

Health Care Financing Administration, S1-03-08, 7500 Security Blvd.,

Baltimore, MD 21244-1850, Telephone (410) 786-5255.

Questions concerning Medicaid items in Addenda III may be addressed

to Pat Prete, Medicaid Bureau, Office of Medicaid Policy, Health Care

Financing Administration, (before July 21, 1995) Room 233 East High

Rise, 6325 Security Blvd., Baltimore, MD 21207, Telephone (410) 966-

3246 or (after July 21, 1995) C4-25-02, 7500 Security Boulevard,

[[Page 38346]]

Baltimore, MD 21244-1850, Telephone (410) 786-3246.

Questions concerning all other information may be addressed to

Nancy Ranels, Office of Regulations, Bureau of Policy Development,

Health Care Financing Administration, (before August 4, 1995) Room 132

East High Rise 6325 Security Blvd., Baltimore, MD 21207, Telephone

(410) 966-8928 or (after August 4, 1995) C5-14-22, 7500 Security

Boulevard, Baltimore, MD 21244-1850, Telephone (410) 786-8928.

(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: July 19, 1995.

Bruce C. Vladeck,

Administrator, Health Care Financing Administration.

Addendum I

This addendum lists the publication dates of the most recent

quarterly listing of program issuances and coverage decision updates to

the Coverage Issues Manual. For a complete listing of the quarterly

updates to the Coverage Issues Manual published between March 20, 1990

through November 14, 1994, please refer to the January 3, 1995 update

(60 FR 134).

January 3, 1995 (60 FR 132)

April 6, 1995 (60 FR 17538)

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

[January Through March 1995]

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Trans. No. Manual/Subject/Publication Number

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Medicare

Intermediary Manual--Part 2

Audits, Reimbursement

Program Administration (HCFA-Pub. 13-2)

(Superintendent of Documents No. HE 22.8/6-1)

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402 Maximum Payment For Rural Health Clinics

Maximum Payment For Federally Qualified Health

Centers

403 Contractor Performance Evaluation

Fiscal Intermediary Performance Criteria--

General

The RHHI Performance Evaluation

RHHI Performance Criteria--General

404 Beneficiary Services

Provider Services

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Medicare

Intermediary Manual--Part 3

Claims Process (HCFA-Pub. 13-3)

(Superintendent of Documents No. HE 22.8/6)

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1642 HCPCS for Hospital Outpatient Radiology Services

and Other Diagnostic Procedures

Ambulatory Surgical Center Pricer Program

1643 Billing for Durable Medical Equipment, Orthotic/

Prosthetic Devices and Surgical Dressings

1644 Frequency of Billing

Requirement That Bills Be Submitted In-Sequence

for a Continuous Inpatient Stay

Need to Reprocess Inpatient Claims In-Sequence

1645 PRO Reporting on Medical Review

1646 All-Inclusive Rate Providers

Billing for Parenteral and Enteral Nutrition

Special Billing Instructions for Pneumococcal

Pneumonia

1647 On-Site CMRs

Review Options

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Medicare

Carriers Manual--Part 2

Program Administration (HCFA-Pub. 14-2)

(Superintendent of Documents No. HE 22.8/7-3)

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130 The FY 1995 Contractor Performance Evaluation

131 Beneficiary Services

Provider Services

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Medicare

Carriers Manual--Part 3

Claims Process (HCFA-Pub. 14-3)

(Superintendent of Documents No. HE 22.8/7)

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1508 Medical Review

Local MR Policy

The Carrier Advisory Committee

[[Page 38347]]

Data Analysis to Identify Aberrancies

Aberrancies

Taking Corrective Actions on Identified

Aberrancies

Conducting Evaluation of Effectiveness of

Correction Action

Standard Postpayment Data Reports

Categories of MR Screens

Provider Audit List

CMR Corrective Actions

Assessing an Overpayment or Potential

Overpayment When the CMR was Based on a Limited

Sample/Subsample

Determination

Consent Settlement Documents

1509 Participating Physician/Supplier Report

Completion of Items on Participating Physician/

Supplier Report

Checking Reports

1510 Recovery From the Physician/Supplier--

Overpayment Demand Letters

Initial Demand Letter to Physicians/Suppliers

Follow-up Demand Letter to Physicians/Suppliers

Overpayment Report

Optional Overpayment Customizing Paragraphs

Sample Letter--Check Included For Correct Amount

Sample Letter--Check Included But Wrong Amount

1511 Personal Computer EMC Software

1512 HCFA Common Procedure Coding System

Use and maintenance of CPT-4 in HCPCS

Local Codes at Regular Carriers

Use and Acceptance of HCPCS Codes and Modifiers

HCPCS Update

Payment Concerns While Updating Codes

Payment, Utilization Review and Coverage

Information on HCFA Tape File

Deleted HCPCS Codes/Modifiers

Claims Review and Adjudication Procedures

HCPCS Release

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Program Memorandum

Intermediaries (HCFA-Pub. 60A)

(Superintendent of Document No. HE 22.8/7)

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A-95-1 Hospital Outpatient Procedures: 1995 Update to

the List of Radiology Procedures and Other

Diagnostic Services Subject to Payment

Limitation and Update to the List of HCPCS

Codes to Be Grossed-Up

A-95-2 Submission of Form HCFA-2552-92 (Hospital and

Hospital Health Care Complex Cost Report)

A-95-3 Ambulatory Surgical Center--PRICER 9.1

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Program Memorandum

Carriers (HCFA-Pub. 60B)

(Superintendent of Documents No. HE 22.8/6-5)

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B-95-1 Implementation of 1995 Physician Fee Schedule

Payment Policy Changes

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Program Memorandum

Intemediaries/Carriers (HCFA-Pub. 60AB)

(Superintendent of Documents No. HE 22.8/6-5)

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AB-95-1 Establishment of Standard Rates for Transmitting

Claims Information Between Medicare Contractors

and Complementary Insurers

AB-95-2 New Interest Rate Payable on Clean Claims Note

Paid Timely

AB-95-3 Implementation of ``Physician Ownership and

Referral'' (Section 1877 of the Social Security

Act, as amended by Section 13562 of the Omnibus

Budget Reconciliation Act of 1993 (OBRA 93))

AB-95-4 EDI Enrollment Form

AB-95-5 Temporary HCPCS Codes for Dexamethasone Acetate

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Program Memorandum

Medicaid State Agencies (HCFA-Pub. 17)

(Superintendent of Documents No. HE 22.8/6-5

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95-1 Title XIX, Social Security Act, Transfers of

Assets and Treatment of Trusts

------------------------------------------------------------------------

[[Page 38348]]

Program Memorandum

Insurance Commissioners (HCFA-Pub. 80)

(Superintendent of Documents No. HE 22.8/6-5)

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95-1 Medigap Bulletin Series (Number Four)

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State Operations Manual

Provider Certification (HCFA-Pub. 7)

(Superintendent of Documents No. HE 22.8/12)

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266 Survey Procedures for Swing-Bed Hospitals

Model Letter--Swing Bed Applicants

Nurse Aide Training/Nurse Aide Training and

Competency Evaluation Program

Line-Item Justification for Direct and Indirect

Costs

Preparation of the State Survey Agency

Certification Workload Report--HCFA-434

Distribution of Approved Funds

Disbursement of Approved Funds

General

Goods, Facilities, Services From Other Staff

Agencies or From Local Agencies

Personnel Services

State Agency Accounts

Determination of Necessary Staff

Communications and Supplies

Equipment

Training of State Agency Personnel

Long Term Care Facility Workload (SNF/NF)

Preparation of the State Agency Budget List of

Positions--HCFA-1465A

Preparation of the State Agency Schedule for

Equipment Purchases--HCFA-1466

Preparation of State Survey Agency Budget

Request (Non-LTC)-HCFA-435

Preparation of State Survey Agency Budget

Request--Long-Term Care, HCFA-435

Submittal of Budget Request

Notification of Approval

Need For Additional Title XVIII and Title XIX

Funds

Financial Reporting

Limit on Expenditures

Periodic Analysis of Accounts

Cash Balances and Expenditure Authority

Unliquidated Obligations

State Survey Agency Quarterly Expenditure

Report, HCFA-435 and State Survey Agency

Certification Workload Report HCFA-434--

Submittal and Due Date

Preparation of State Survey Agency Non-TLC

Quarterly Expenditure Report, HCFA-435

Preparation of State Survey Agency Long-Term

Care Quarterly Expenditure Report, HCFA-435

State Survey Agency/Certification Workload

Report

267 Community Mental Health Centers--Citations and

Description

Certification Process

Model Letter to CMHCs

CMHC Crucial Data Extract

Public Health Service Act Requirements

Health Insurance Benefit Agreement

Conditions to Be Assessed Prior to Scheduling An

RHC Survey

268 Assignment of Provider and Supplier

Identification Numbers

Essential Access Community Hospital//Rural

Primary Care Hospital (EACH/RPCH) Program--

Citations and Description

Procedures for EACH Approval by the Regional

Office (RO)

Procedures for RPCH Approval by the RO

Procedures for Processing RPCH Swing-Bed

Applications

Processing Complaints Against EACHs and RPCHs

Processing Denials and Terminations for EACHs

and RPCHs

EACH Approval Letter

RPCH Approval Letter

EACH Denial Letter

RPCH Denial Letter

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Medicare

Hospital Manual (HCFA-Pub. 10)

(Superintendent of Documents No. HE 22.8/2)

------------------------------------------------------------------------

675 HCPCS for Hospital Outpatient Radiology Services

and Other Diagnostic Procedures

676 Billing for Durable Medical Equipment, Orthotic/

Prosthetic Devices and Surgical Dressings

677 Oral Cancer Drugs

Requirement That Bills Be Submitted In-Sequence

for a Continuous Inpatient Stay

678 Pneumococcal Pneumonia, Influenza Virus and

Hepatitis B Vaccines

------------------------------------------------------------------------

Medicare

Home Health Agency Manual (HCFA-Pub. 11)

(Superintendent of Documents No. HE 22.8/5)

------------------------------------------------------------------------

274 Pneumococcal Pneumonia, Influenza Virus and

Hepatitis B Vaccines

------------------------------------------------------------------------

Medicare

Skilled Nursing Facility Manual (HCFA-Pub. 12)

(Superintendent of Documents No. HE 22.8/3)

------------------------------------------------------------------------

334 Billing for Durable Medical Equipment, Orthotic/

Prosthetic Devices and Surgical Dressings

335 Requirement That Bills Be Submitted In-Sequence

For a Continuous Inpatient Stay

336 Special Billing Instructions for Pneumococcal

Pneumonia, Influenza Virus and Hepatitis B

Vaccines

------------------------------------------------------------------------

Medicare

Rural Health Clinic and Federally

Qualified Health Centers Manual (HCFA-Pub. 27)

(Superintendent of Documents No. HE 22.8/19:985)

------------------------------------------------------------------------

18 Rural Health Clinics

Federally Qualified Health Centers

19 Billing of Pneumococcal Pneumonia, Influenza

Virus and Hepatitis B Vaccines by Rural Health

Clinics and Federally Qualified Health Centers

------------------------------------------------------------------------

Medicare

Hospice Manual (HCFA-Pub. 21)

(Superintendent of Documents No. HE 22.8/18)

------------------------------------------------------------------------

45 Special Billing Instructions for Pneumococcal

Pneumonia, Influenza Virus and Hepatitis B

Vaccines

------------------------------------------------------------------------

Medicare

Provider Reimbursement Manual Part 1 (HCFA-Pub. 15-1)

(Superintendent of Documents No. HE 22.8/4)

------------------------------------------------------------------------

380 Board Action on Request for Hearing

381 Ancillary Services in SNFs

382 Principles

Land (Non-Depreciable)

Historical Cost

Purchase of Facility as Ongoing Operation

Fair Market Value

Donated Assets

Net Book Value

Acquisitions

Sale and Leaseback Agreements--Rental Charges

[[Page 38350]]

Lease Purchase Agreements--Rental Charges

Assets Partially or Fully Depreciated on

Provider's Books When Provider Enters Program

Transfer of Governmental Facilities

Assets Donated to Provider

Useful Life of Depreciable Assets

------------------------------------------------------------------------

Medicare

Provider Reimbursement Manual

Part II--Provider Cost Reporting Forms and Instructions (HCFA-Pub. 15-

11AF)

(Superintendent of Documents No. HE 22.8/4)

------------------------------------------------------------------------

1 Home Health Agency Cost Report, Form HCFA-1728-

94

2 Rounding Standards for Fractional Computations

Method of Payment

Worksheet S--Independent Renal Dialysis Facility

Cost Report Certification

Worksheet A--Reclassification and Adjustments of

Trial Balance of Expenses

Worksheet A-2--Adjustments to Expenses

Worksheet B, Cost Allocation--General Service

Costs and Worksheet B-1--Cost Allocation--

Statistical Basis

------------------------------------------------------------------------

Medicare

Provider Reimbursement Manual

Part II--Provider Cost Reporting Forms

and Instructions (General) (HCFA-Pub. 15-11A)

(Superintendent of Documents No. HE 22.8/4)

------------------------------------------------------------------------

17 Submission of Cost Reports

------------------------------------------------------------------------

Medicare

Outpatient Physical Therapy and

Comprehensive Outpatient Rehabilitation Facility

Manual (HCFA-Pub. 9)

(Superintendent of Documents No. HE 22.8/9)

------------------------------------------------------------------------

120 Billing for Durable Medical Equipment, Orthotic/

Prosthetic Devices and Surgical Dressing

121 Pneumococcal Pneumonia, Influenza Virus and

Hepatitis B Vaccines

122 Pneumococcal Pneumonia, Influenza Virus and

Hepatitis B Vaccines

------------------------------------------------------------------------

Peer Review Organization Manual

(HFCA-Pub. 19)

(Superintendent of Documents No. HE 22.8/15)

------------------------------------------------------------------------

44 Introduction

HCFA-Provided Data

PRO-Selected Data

Confidentiality of PRO Data

45 Training

46 Objectives of the Internal Quality Control

Program

IQC Program Requirements

IQC Control Process

Analysis and Reporting Requirements

47 Introduction

Uses for PDC

Conducting PDC

Concerns Identified During PDC

Confidentiality

Reports to HCFA

Required HCFA Notification/Approval

Office of Management and Budget Clearance

Related Activities Through PRO/Carrier

Intermediary/ESRD Network Cooperation

Timeline for PDC Process

48 Statutory Basis

Grounds for Termination

Recommendation to Initiate Termination

Notice of Intent to Terminate Contract

Termination Panel

Termination Decision

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[[Page 38351]]

Medicare

Coverage Issues Manual (HCFA-Pub. 6)

(Superintendent of Documents No. 22. 8/14)

------------------------------------------------------------------------

74 Bladder Stimulators (Pacemakers)

------------------------------------------------------------------------

State Medicaid Manual

Part 3--Eligibility (HCFA-Pub. 45-6)

(Superintendent of Documents No. HE 22.8/10)

------------------------------------------------------------------------

65 Persons with Drug Addition or Alcoholism

------------------------------------------------------------------------

State Medicaid Manual

Part 6--Payment for Services (HCFA-Pub. 45-6)

(Superintendent of Documents No. HE 22.8/10)

------------------------------------------------------------------------

27 Physician Services to Children Under 21

Physican Services to Pregnant Women

------------------------------------------------------------------------

End Stage Renal Disease

Network Organizations Manual (HCFA-Pub. 81)

(Superintendent of Documents No. HE 22.9/4)

------------------------------------------------------------------------

2 Introduction

Board of Directors

Network Staff

Network Council

Patient Involvement

Medical Review Board

Other Committees

Meetings

Goals

Internal Quality Control System

Continuous Quality Improvement

Medicare Benefits for ESRD Patients

Hospital Insurance for Persons Needing Kidney

Transplant or Dialysis

When ESRD Coverage Begins

When ESRD Coverage Ends

Supplemental Medical Insurance

Organizational Conflicts of Interest Among

Governing Body of ESRD Network Organizations,

Facilities, and Patients

Conflict of Interest--Private Arrangements

Prohibited

Organizational Conflicts of Interest

Permitted Activities

------------------------------------------------------------------------

Medicare

Renal Dialysis Facility Manual (HCFA-Pub. 29)

(Superintendent of Document No. HE 22.8/13)

------------------------------------------------------------------------

71 Pneumococcal Pneumonia, Influenza Virus and

Hepatitis B Vaccines

------------------------------------------------------------------------

Medicare/Medicaid

Sanction/Reinstatement Report

------------------------------------------------------------------------

95-1 Report of Physicians/Practitioners, Providers

and/or Other Health Care Suppliers Excluded/

Reinstated

95-2 Report of Physicians/Practitioners, Providers

and/or Other Health Care Suppliers Excluded/

Reinstated

95-3 Report of Physicians/Practitioners, Providers

and/or Other Health Care Suppliers Excluded/

Reinstated

------------------------------------------------------------------------

Addendum IV--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. 74; sections 65-10.1-65-11 Bladder Stimulators

(Pacemakers) CHANGED IMPLEMENTING INSTRUCTIONS--EFFECTIVE DATE: For

services performed on or after 03-01-95.

Section 65-10.1, Bladder Stimulators (Pacemakers).--This section is

revised to reflect that pelvic floor stimulators, whether inserted into

the vaginal canal or rectum or implanted in the pelvic area, used as a

treatment for urinary incontinence either as a bladder pacer or a

retraining mechanism are not covered for the reason that the safety

[[Page 38352]]

and effectiveness of these devices are unproven.

65-11 BLADDER STIMULATORS (PACEMAKERS)--NOT COVERED Pelvic floor

stimulators, whether inserted into the vaginal canal or rectum or

implanted in the pelvic area, used as a treatment for urinary

incontinence either as a bladder pacer or a retraining mechanism are

not covered for the reason that the safety and effectiveness of these

devices are unproven.

Addendum V.--Regulation Documents Published in the Federal Register

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End of

Publication date FR vol. 60 page CFR part File code Regulation title comment Effective

period date

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01/03/95........ 46-54........... 410,414......... BPD-789-CN Medicare Program; Refinements to Geographic Adjustment ........... 01/01/95

Factor Values, Revisions to Payment Policies,

Adjustments to the Relative Value Units (RVUs) Under

the Physician Fee Schedule for Calendar Year 1995,

and the 5-Year Refinement of RVUs.

01/03/95........ 130-132......... ................ HSQ-224-N CLIA Program: Approval of the Joint Commission on ........... 01/03/95

Accreditation of Healthcare Organizations As An

Accrediting Organization.

01/03/95........ 132-141......... ................ BPO-129-N Medicare and Medicaid Programs; Quarterly Listing of ........... 01/03/95

Program Issuances and Coverage Decisions--Third

Quarter 1994.

1/09/95......... 2325-2330....... 400, 405, 410, BPD-798-FC Medicare Program; Providers and Suppliers of 03/10/95 02/08/95

484, 485, 486, Specialized Services: Technical Amendments.

498,.

01/13/95........ 3250-3253....... ................ MB-089-N Medicaid Program; Limitations on Aggregate Payments to ........... 01/13/95

Disproportionate Share Hospitals: Federal Fiscal Year

1995.

01/17/95........ 3405-3410....... ................ BPD-778-FN Medicare Program; Special Payment Limits for Home ........... 02/16/95

Blood Glucose Monitors.

01/23/95........ 4418-4423....... ................ ORD-070-N New and Pending Demonstration Project Proposals ........... 01/23/95

Submitted Pursuant to Section 1115(a) of the Social

Security Act: November and December 1994.

01/26/95........ 5185-5204....... ................ BPD-776-FNC Medicare Program; Additions To and Deletions From the 03/27/95 02/27/95

Current List of Covered Surgical Procedures for

Ambulatory Surgical Centers.

02/02/95........ 6537-6547....... ................ BPD-812-NC Medicare Program; Criteria for Medicare Coverage of 04/03/95 02/02/95

Lung Transplants.

02/08/95........ 7514............ 482............. BPD-826-N Medicare Program; Hospice Wage Index.................. ........... 02/08/95

02/09/95........ 7774-7780....... ................ HSQ-223-N CLIA Program: Approval of the College of American ........... 02/09/95

Pathologists.

02/14/95........ 8389-8406....... ................ BPD-793-NC Medicare Program; Schedule of Limits on Home Health 04/17/95 07/01/94

Agency Costs Per Visit.

02/16/95........ 8951-8955....... 410............. BPD-424-F Medicare Program; Medicare Coverage of Prescription ........... 01/01/95

Drugs Used in Immunosuppressive Therapy.

02/24/95........ 10395-10396..... ................ OPL-004-N Medicare Program; Meeting of the Practicing Physicians ........... 02/24/95

Advisory Council.

03/02/95........ 11632-11633..... 485, 486........ BPD-798-CN Medicare Program; Providers and Suppliers of ........... 02/08/95

Specialized Services-Technical Amendments;

Corrections.

03/13/95........ 13441........... ................ BPD-833-N Medicare Program; Hospice Wage Index.................. ........... 03/13/95

03/16/95........ 14223-14224..... 410............. BPD-724-F Medicare Program; Medicare Coverage of Screening ........... 10/01/94

Mammography; Correction.

03/30/95........ 16481-16486..... ................ ORD-073-N New and Pending Demonstration Project Proposals ........... ...........

Submitted Pursuant to Section 1115(a) of the Social

Security Act: January 1995.

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*GN--General Notice; PN--Proposed Notice; FN--Final Notice; P--Notice of Proposed Rulemaking (NPRM); F--Final Rule: FC--Final Rule with Comment Period;

CN--Correction Notice; SN--Suspension Notice; WN--Withdrawal Notice; NR--Notice of HCFA Ruling

[FR Doc. 95-18333 Filed 7-25-95; 8:45 am]

BILLING CODE 4120-01-P