[Federal Register Volume 60, Number 1 (Tuesday, January 3, 1995)]
[Notices]
[Pages 132-141]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-32295]



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

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:
    <bullet> Titles XI, XVIII, and XIX of the Act.
    <bullet> HCFA-related regulations.
    <bullet> HCFA manuals and monthly revisions. [[Page 134]] 
    <bullet> 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.                                                                                 
----------------------------------------------------------------------------------------------------------------


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