```

[Federal Register Volume 75, Number 78 (Friday, April 23, 2010)]
[Proposed Rules]
[Pages 21207-21211]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2010-8903]

=======================================================================
-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Service

42 CFR Part 416

[CMS-3217-P]
RIN 0938-AP93

Medicare Program; Ambulatory Surgical Centers, Conditions for 
Coverage

AGENCY: Centers for Medicare & Medicaid Services (CMS).

ACTION: Proposed rule.

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

SUMMARY: This proposed rule would revise one of the existing conditions 
for coverage (CfC) that ambulatory surgical centers (ASCs) must meet in 
order to participate in the Medicare program. The proposed revision 
would modify the current CfC for patient rights to include an exception 
that would allow an ASC to provide patients or the patients' 
representative or surrogate with required patient rights information on 
the day of the procedure when the procedure must, to safeguard the 
health of the patient, be performed on the same day as the physician's 
referral. In addition, we are proposing some other minor changes to the 
CfC for patient right requirements.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. EST on June 22, 
2010.

ADDRESSES: In commenting, please refer to file code CMS-3217-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.

[[Page 21208]]

    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the instructions under 
the ``More Search Options'' tab.
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-3217-P, P.O. Box 8010, 
Baltimore, MD 21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-3217-P, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 
20201.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-9994 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.

FOR FURTHER INFORMATION CONTACT: Joan A. Moliki, (410) 786-5526, 
Jacqueline Morgan, (410) 786-4282, Steve Miller, (410) 786-6656, or 
Jeannie Miller, (410) 786-3164.

SUPPLEMENTARY INFORMATION:
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

A. Legislative and Regulatory Authority for the Ambulatory Surgical 
Centers, Conditions for Coverage

    As the single largest payer for health care services in the United 
States, the Centers for Medicare & Medicaid Services (CMS) has a 
critical role in promoting high quality care for Medicare 
beneficiaries. CMS is responsible for ensuring that the conditions for 
coverage (CfCs) of Ambulatory Surgical Center (ASC) services, and 
enforcement of those conditions, are adequate to protect the health and 
safety of the individuals treated in such ASCs. Any regulatory changes 
that we contemplate must consider patient health and safety along with 
the administrative burden placed on Medicare-participating facilities.
    Section 1832(a)(2)(F)(i) of the Social Security Act (the Act) 
specifies that an ASC must meet health, safety, and other requirements 
specified by the Secretary of Health and Human Services (HHS) (the 
Secretary) in regulation if it has an agreement in effect with the 
Secretary to perform procedures covered by Medicare. Under the 
agreement, the ASC agrees to accept the standard Medicare amount 
determined under section 1833(i)(2) of the Act as full payment for 
services, and to accept assignment of benefits as described in section 
1842(b)(3)(B)(ii) of the Act for payment for all services furnished by 
the ASC to enrolled individuals. Substantive requirements are set forth 
in 42 CFR part 416 subpart B and subpart C of our regulations. The 
regulations at 42 CFR part 416 subpart B describe the general 
conditions and requirements for ASCs, and the regulations at 42 CFR 
part 416 subpart C describe the specific CfCs for ASCs.

B. Updates and Revisions to the Ambulatory Surgical Centers Conditions 
for Coverage

    On August 31, 2007, we published a proposed rule (72 FR 50470) in 
the Federal Register entitled, ``Medicare and Medicaid Programs; 
Ambulatory Surgical Centers, Conditions for Coverage,'' in which we 
proposed to update the ASC CfCs by revising some of the definitions and 
the CfCs regarding governing body and management, and laboratory and 
radiologic services, to reflect current ASC practices. In addition, we 
proposed to add several new CfCs regarding quality assessment and 
performance improvement; patient rights; infection control; and patient 
admission, assessment and discharge. We proposed these CfCs in order to 
promote and protect patient health and safety.
    In the proposed rule at Sec.  416.50, we proposed to divide the 
patient rights CfC into four standards. Under the first standard, Sec.  
416.50(a)(1), ``Notice of rights,'' we proposed that ASCs be required 
to provide the patient or the patient's representative with verbal and 
written notice of the patient's rights in a language and manner the 
patient understood in advance of providing care to the patient. In 
addition, we set out what information would be required and where the 
ASC would have to post the information for the patient to see while 
waiting for treatment.
    On November 18, 2008, we published a final rule (73 FR 68502), 
entitled ``Medicare Program; Changes to the Hospital Outpatient 
Prospective Payment System and CY 2009 Payment Rates''. The final rule, 
among other changes, finalized the new CfC for patient rights in ASCs. 
In response to the proposed patient rights provision, several 
commenters expressed concern about the amount of paperwork patients 
would be required to complete on the day of the procedure and stated 
that patients would benefit from reviewing pertinent information before 
they arrived at the ASC for the procedure (see 73 FR 68718). Therefore, 
in response to comments, we revised our proposed requirement for 
patient rights at Sec.  416.50(a)(1), (a)(1)(ii) and (a)(2)(i), to 
specify that ambulatory surgical centers (ASCs) provide patient rights 
information to patients or the patient's representative in advance of 
the date of the procedure.

[[Page 21209]]

    When we published the final rule for the ASC CfCs on November 18, 
2008, we specified at Sec.  416.50(a)(1) that patient rights 
information was to be provided by the ASC in advance of the date of the 
procedure. It was, and continues to be, our intent to require that ASCs 
provide patients or the patient's representative or surrogate with 
information we believe they need in order to make an informed choice 
about the facility where their procedure will be performed. Likewise, 
we continue to believe that this information should be imparted in 
advance of the date of the procedure.
    The patient's representative or surrogate, who could be a family 
member or friend that accompanies the patient, may act as a liaison 
between the patient and the ASC to help the patient communicate, 
understand, remember, and cope with the interactions that take place 
during the visit, and explain any instructions to the patient that are 
delivered by the ASC staff. If a patient is unable to fully communicate 
directly with the ASC staff, then the ASC may give patient rights 
information to the patient's representative or surrogate. The patient 
has the choice of using an interpreter of his or her own, or one 
supplied by the ASC. A professional interpreter is not considered to be 
a patient's representative or surrogate. Rather, it is the professional 
interpreter's role to pass information from the ASC to the patient. In 
following translation practices, we recommend, but do not propose 
requiring, that a written translation be provided in languages that 
non-English speaking clients can read, particularly for languages that 
are most commonly used by non-English-speaking clients of the ASC. We 
note that there are many hundreds of languages (not all written) that 
are used by one or more residents of the United State, but that in most 
geographic areas the most common non-English language, by far, is 
Spanish.
    While we propose this standard under the authority of title 18, 
section 1832(a)(2)(F)(i), there are other legal requirements, most 
notably, those under title VI of the Civil Rights Act of 1964. Our 
proposed requirement has been designed to be compatible with recent 
guidance on title VI. The Department of Health and Human Services' 
(HHS) guidance related to Title VI of the Civil Rights Act of 1964, 
``Guidance to Federal Financial Assistance Recipients Regarding Title 
VI Prohibition Against National Origin Discrimination Affecting Limited 
English Proficient Persons'' (August 8, 2003, 68 FR 47311) applies to 
those entities that receive federal financial assistance from HHS, 
including ASCs. This guidance may assist ASCs in ensuring that patient 
rights information is provided in a language and manner the Medicare 
patient understands.
    In the November 18, 2008, ASC regulation, we also specified at 
Sec.  416.50(a)(1)(ii) (physician financial interest or ownership), and 
Sec.  416.50(a)(2)(i) (Advance directives) that ASCs are also required 
to provide this information to patients in advance of the date of the 
procedure. We believe that the current organization of Sec.  416.50 is 
confusing relative to the need for ASCs to furnish information to 
patients prior to the date of the procedure. Therefore, we are 
proposing to revise this section.

II. Provisions of the Proposed Regulation

    As stated above, the November 18, 2008 final rule finalized the 
patient's right provision at Sec.  416.50, to require ASCs to provide 
specific patients' rights information to patients in advance of the 
date of the procedure. We believed this modification would alleviate 
provider concerns while at the same time afford patients sufficient 
time to review pertinent information before undergoing a procedure. 
However, since the publication of the final rule, it has come to our 
attention that a few ASCs sometimes provide same-day procedures on an 
emergency basis. Therefore, the current patient rights CfC requirement 
has been problematic for those ASCs that perform procedures on the same 
day they receive physician referrals (for example, a patient is 
referred to an ASC due to severe eye trauma).
    ASCs contemplating providing services to a patient on the same day 
he or she receives a referral must either refuse serving the patient 
for fear of violating Medicare requirements or accept the patient for 
service and be out of compliance with Medicare patient rights 
requirements. ASCs that serve same-day patients would like to continue 
to serve this constituency; however, potential non-compliance with the 
current Medicare requirement is a deterrent.
    This rule proposes to establish an exception when an ASC is 
providing services to a patient on the same day he or she receives a 
physician referral for the ASC service(s) and when a delay in providing 
the service(s) would adversely affect the patient's health. In general, 
the ASC would continue to be required to provide information as 
specified at Sec.  416.50. However, the proposed exception would apply 
only if: (1) The written referral was signed and dated by the physician 
on the date the patient was presented at the ASC for the service(s); 
and (2) a physician in the ASC or the referring physician communicates 
in writing and the ASC documents in the medical record that the 
procedure must be performed as soon as possible to safeguard the health 
of the patient. This proposed exception attempts to balance our 
responsibility to promote the health and safety of ASC patients with 
undue burden on facilities.
    In addition to modifying Sec.  416.50 to provide for an exception 
for same-day procedures, we are proposing minor revisions to this 
section. Currently Sec.  416.50(a)(1) and (a)(2) require disclosure of 
information to be made in advance of the date of the procedure. We are 
proposing to eliminate this specific requirement from these sections 
and add this requirement to the stem statement at Sec.  416.50 since 
the stem statement applies to all of the proposed requirements at Sec.  
416.50.
    The current provisions at Sec.  416.50(a), (b), and (c) require 
that an ASC provide verbal and written notice of patient rights to the 
patient or the patient's representative. This encompasses the posting 
of rights, disclosure of physician financial interest or ownership, the 
provision of advance directives, the submission and investigation of 
grievances, the exercise of rights, privacy and safety, and the 
confidentiality of clinical records. We are proposing to reorganize 
Sec.  416.50(a), (b), and (c) by creating separate standards for 
provisions that are currently required in these paragraphs. 
Specifically, we are proposing to retitle and reorganize the 
requirements of Sec.  416.50, ``Patient rights,'' as follows: (a) 
Standard: Notice of rights; (b) Standard: Disclosure of physician 
financial interest or ownership; (c) Standard: Advance directives; (d) 
Standard: Submission and investigation of grievances; (e) Standard: 
Exercise of rights and respect for property and person; (f) Standard: 
Privacy and safety; (g) Standard: Confidentiality of medical records; 
and (h) Standard: Exception to the timing of the notice of patient 
rights. We believe this reorganization would eliminate confusion about 
the patient rights information to be provided to patients. We note that 
these are not new requirements.
    In addition, as stated above, we are proposing to add a new 
exception to Sec.  416.50 (proposed Standard (h)) that would allow an 
ASC in the case of an emergency procedure, and when it was not feasible 
to provide notice of patient rights information in advance of the date 
of the procedure, to provide this information to the patient or the

[[Page 21210]]

patient's representative or surrogate on the day of treatment before 
the procedure.

III. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995, we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the Paperwork Reduction Act 
of 1995 requires that we solicit comments on the following issues:
     The need for the information collection and its usefulness 
in carrying out the proper functions of our agency.
     The accuracy of our estimate of the information collection 
burden.
     The quality, utility, and clarity of the information to be 
collected.
     Recommendations to minimize the information collection 
burden on the affected public, including automated collection 
techniques.
    Proposed Sec.  416.50 (h)(1) and (h)(2) would require an ASC 
facility to furnish information as specified when an ASC accepts a 
patient for a procedure that must be performed on the same day as a 
physician referral. Specifically, proposed Sec.  416.50(h)(2) states 
that a physician in the ASC or the referring physician must communicate 
in writing and the ASC must document in the medical record that the 
procedure be performed as soon as possible to safeguard the health of 
the patient. The burden associated with this requirement is the time 
and effort necessary for an ASC physician or a referring physician to 
make the aforementioned written communication and documentation.
    We believe the burden associated with this requirement in proposed 
Sec.  416.50 constitutes a usual and customary business practice as 
defined in 5 CFR 1320.3(b)(2). The medical record requirement at Sec.  
416.47, which remains unchanged, also specifies that ASCs must maintain 
complete, comprehensive and accurate medical records to ensure adequate 
patient care. A physician referral letter is considered part of the 
patient's medical history and is always part of the medical record.
    If you comment on these information collection and recordkeeping 
requirements, please do either of the following:
    1. Submit your comments electronically as specified in the 
ADDRESSES section of this proposed rule; or
    2. Submit your comments to the Office of Information and Regulatory 
Affairs, Office of Management and Budget, Attention: CMS Desk Officer, 
CMS-3217-P, Fax: (202) 395-6974; or E-mail: OIRA_submission@omb.eop.gov.

IV. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble, 
and, when we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.

V. Regulatory Impact Statement

    We have examined the impacts of this rule as required by Executive 
Order 12866 on Regulatory Planning and Review (September 30, 1993), the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), 
section 1102(b) of the Social Security Act, section 202 of the Unfunded 
Mandates Reform Act of 1995 (Pub. L. 104-4), Executive Order 13132 on 
Federalism (August 4, 1999), and the Congressional Review Act (5 U.S.C. 
804(2)).
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). This rule 
does not reach the economic threshold and thus is not considered a 
major rule.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and small governmental 
jurisdictions. Most hospitals and most other providers and suppliers 
are small entities, either by nonprofit status or by having revenues of 
$7.0 million to $34.5 million in any 1 year. Individuals and States are 
not included in the definition of a small entity. We estimate there are 
approximately 5,100 Medicare Participating ASCs with average admissions 
of approximately 1,240 patients per ASC (based on the number of 
patients seen in ASCs in 2008). Most ASCs are considered to be small 
entities, either by nonprofit status or by having revenues of $7 
million to $34.5 million in any 1 year. For purposes of burden 
estimates, we are unable to accurately determine the exact number of 
ASCs that provide services to patients on the same day as referral by 
their physicians. However, one national ASC chain informed us in 
September 2009 that approximately 3 percent of its ASCs provide 
services to patients on the same day as referral by their physicians. 
Using this percentage, we estimate that 153 ASCs overall perform these 
same day services. Due to this small percentage, we have determined 
that the ASC industry on average will experience a slightly reduced 
burden associated with mailing out patient rights informational packets 
to patients prior to providing the service(s). Instead, a small 
percentage of patients would be informed in person on the day of the 
procedure. Thus, we believe this exception rule should have little or 
no effect on the benefit cost of ASC services.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 603 of the RFA. 
However, this proposed rule only affects ambulatory surgical centers 
and not hospitals. As a result, we are not preparing an analysis for 
section 1102(b) of the Act because we believe and the Secretary has 
determined that this rule will not have a significant impact on the 
operations of a substantial number of small rural hospitals.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year by 
State, local or tribal governments, in the aggregate, or by the private 
sector of $100 million in 1995 dollars, updated annually for inflation. 
In 2010, that threshold level is approximately $135 million. This 
proposed rule is not expected to reach this spending threshold.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. This proposed rule has no Federalism implications and 
does not impose any costs on State or local governments. Therefore, the 
requirements of

[[Page 21211]]

Executive Order 13132 are not applicable.
    In accordance with the provisions of Executive Order 12866, this 
regulation was not reviewed by the Office of Management and Budget.

List of Subjects in 42 CFR Part 416

    Health facilities, Health professions, Medicare, Reporting and 
recordkeeping requirements.

    For the reasons set forth in the preamble, the Centers for Medicare 
& Medicaid Services proposes to amend 42 CFR part 416 as set forth 
below:

PART 416--AMBULATORY SURGICAL SERVICES

    1. The authority citation for part 416 continues to read as 
follows:

    Authority:  Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh).

Subpart C--Specific Conditions for Coverage

    2. Section 416.50 is revised to read as follows:

Sec.  416.50  Condition for coverage--Patient rights.

    The ASC must inform the patient or the patient's representative or 
surrogate of the patient's rights and must protect and promote the 
exercise of these rights, as set forth in this section. The ASC must 
also post the written notice of patient rights in a place or places 
within the ASC likely to be noticed by patients waiting for treatment 
or by the patient's representative or surrogate, if applicable.
    (a) Standard: Notice of rights. Except as set forth in paragraph 
(h) of this section, an ASC must, in advance of the date of the 
procedure, provide the patient or the patient's representative or 
surrogate with verbal and written notice of the patient's rights in a 
language and manner that ensures the patient or the patient's 
representative or surrogate understands all of the patient's rights as 
set forth in this section. The ASC's notice of rights must include the 
address and telephone number of the State agency to whom patients may 
report complaints as well as the Web site for the Office of the 
Medicare Beneficiary Ombudsman.
    (b) Standard: Disclosure of physician financial interest or 
ownership. The ASC must disclose, in accordance with Part 420 of this 
subchapter, and where applicable, provide a list of physicians who have 
financial interest or ownership in the ASC facility. Disclosure of 
information must be in writing.
    (c) Standard: Advance directives. The ASC must comply with the 
following requirements:
    (1) Provide the patient or, as appropriate, the patient's 
representative or surrogate with written information concerning its 
policies on advance directives, including a description of applicable 
State health and safety laws and, if requested, official State advance 
directive forms.
    (2) Inform the patient or, as appropriate, the patient's 
representative or surrogate of the patient's right to make informed 
decisions regarding the patient's care.
    (3) Document in a prominent part of the patient's current medical 
record, whether or not the individual has executed an advance 
directive.
    (d) Standard: Submission and investigation of grievances. The ASC 
must establish a grievance procedure for documenting the existence, 
submission, investigation, and disposition of a patient's written or 
verbal grievance to the ASC. The following criteria must be met:
    (1) All alleged violations/grievances relating, but not limited to, 
mistreatment, neglect, verbal, mental, sexual, or physical abuse, must 
be fully documented.
    (2) Allegations of neglect, mistreatment, sexual or physical abuse 
must be immediately reported to a person in authority in the ASC.
    (3) Only substantiated allegations of neglect, mistreatment, sexual 
or physical abuse must be reported to the applicable State authority or 
the local authority, or both.
    (4) The grievance process must specify timeframes for review of the 
grievance and the provisions of a response.
    (5) The ASC, in responding to the grievance, must investigate all 
grievances made by a patient or the patient's representative or 
surrogate regarding treatment or care that is (or fails to be) 
furnished.
    (6) The ASC must document how the grievance was addressed, as well 
as provide the patient with written notice of its decision. The 
decision must contain the name of an ASC contact person, the steps 
taken to investigate the grievance, the result of the grievance 
process, and the date the grievance process was completed.
    (e) Standard: Exercise of rights and respect for property and 
person.
    (1) The patient has the right to
    (i) Be free from any act of discrimination or reprisal.
    (ii) Voice grievances regarding treatment or care that is (or fails 
to be) provided.
    (iii) Be fully informed about a treatment or procedure and the 
expected outcome before it is performed.
    (2) If a patient is adjudged incompetent under applicable State 
health and safety laws by a court of proper jurisdiction, the rights of 
the patient are exercised by the person appointed under State law to 
act on the patient's behalf.
    (3) If a State court has not adjudged a patient incompetent, any 
legal representative or surrogate designated by the patient in 
accordance with State law may exercise the patient's rights to the 
extent allowed by State law.
    (f) Standard: Privacy and safety. The patient has the right to the 
following:
    (1) Personal privacy.
    (2) Receive care in a safe setting.
    (3) Be free from all forms of abuse or harassment.
    (g) Standard: Confidentiality of medical records. The ASC must 
comply with the Department's rules for the privacy and security of 
individually identifiable health information, as specified at 45 CFR 
parts 160 and 164.
    (h) Standard: Exception to the timing of the notice of patient 
rights. In the case of an emergency procedure, when it is not feasible 
to inform the patient or the patient's representative or surrogate of 
the patient's rights in advance of the date of the procedure, the ASC 
may provide the required notice and disclosures to the patient or the 
patient's representative or surrogate immediately before the procedure 
only if the following conditions are met:
    (1) The signed physician referral is in writing, is dated the day 
the patient presents at the ASC, and is placed in the patient's medical 
record prior to the procedure.
    (2) A physician in the ASC or the referring physician communicates 
in writing and the ASC documents in the medical record that the 
procedure must be performed as soon as possible to safeguard the health 
of the patient.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774, Medicare--
Supplementary Medical Insurance Program)

    Dated: January 21, 2010.
Charlene Frizzera,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: April 5, 2010.
Kathleen Sebelius,
Secretary.
[FR Doc. 2010-8903 Filed 4-22-10; 8:45 am]
BILLING CODE 4120-01-P
```