[Federal Register Volume 60, Number 66 (Thursday, April 6, 1995)]
[Notices]
[Pages 17538-17547]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-8398]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[BPO-130-N]


Medicare and Medicaid Programs; Quarterly Listing of Program 
Issuances and Coverage Decisions--Fourth 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 October, November, and 
December 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 October 1 and December 31, 1994. On August 21, 
1989, we published the content of the Manual (54 FR 34555) and 
indicated that we will publish [[Page 17539]] 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); 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 38 million Medicare beneficiaries and 36 
million Medicaid recipients. Administration of these programs involves 
(1) Providing information to Medicare beneficiaries and Medicaid 
recipients, health care providers, and the public; and (2) effective 
communications with regional offices, State governments, State Medicaid 
Agencies, State Survey Agencies, various providers of health care, 
fiscal intermediaries and carriers who process claims and pay bills, 
and others. To implement the various statutes on which the programs are 
based, we issue regulations under authority granted the Secretary under 
sections 1102, 1871, and 1902 and related provisions of the Social 
Security Act (the Act) and also issue various manuals, memoranda, and 
statements necessary to administer the programs efficiently.
    Section 1871(c)(1) of the Act requires that we publish in the 
Federal Register at least every 3 months a list of all Medicare manual 
instructions, interpretive rules, statements of policy, and guidelines 
of general applicability not issued as regulations. We published our 
first notice June 9, 1988 (53 FR 21730). Although we are not mandated 
to do so by statute, for the sake of completeness of the listing of 
operational and policy statements, we are continuing our practice of 
including Medicare substantive and interpretive regulations (proposed 
and final) published during the 3-month timeframe. Since the 
publication of our quarterly listing on June 12, 1992 (57 FR 24797), we 
decided to add Medicaid issuances to our quarterly listings. 
Accordingly, we are listing in this notice Medicaid issuances and 
Medicaid substantive and interpretive regulations published from 
October 1 through December 31, 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 December 31, 
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 sets forth the revisions to the Medicare Coverage 
Issues Manual that were published during the quarter covered by this 
notice. For the revisions, we give a brief synopsis of the revisions as 
they appear on the transmittal sheet, the manual section number, and 
the title of the section. We present a complete copy of the revised 
material, no matter how minor the revision, and identify the revisions 
by printing in italics the text that was changed. If the transmittal 
includes material unrelated to the revised section, for example, when 
the addition of revised material causes other sections to be 
repaginated, we do not reprint the unrelated material.
    Addendum V lists all substantive and interpretive Medicare and 
Medicaid regulations and general notices published in the Federal 
Register during the quarter covered by this notice. For each item, we 
list the date published, the Federal Register citation, the title of 
the regulation, the parts of the Code of Federal Regulations (CFR) 
which have changed (if applicable), the agency file code number, the 
ending date of the comment period (if applicable), and the effective 
date (if applicable). [[Page 17540]] 

IV. How to Obtain Listed Material

A. Manuals

    An individual or organization interested in routinely receiving any 
manual and revisions to it may purchase a subscription to that manual. 
Those wishing to subscribe should contact either the Government 
Printing Office (GPO) or the National Technical Information Service 
(NTIS) at the following addresses:

Superintendent of Documents, Government Printing Office, Attn: New 
Order, P.O. Box 371954, Pittsburgh, PA 15250-7954, Telephone (202) 512-
1800, Fax number (202) 512-2250 (for credit card orders); or
National Technical Information Service, Department of Commerce, 5825 
Port Royal Road, Springfield, VA 22161, Telephone (703) 487-4630.

    In addition, individual manual transmittals and Program Memoranda 
listed in this notice can be purchased from NTIS. Interested parties 
should identify the transmittal(s) they want. GPO or NTIS can give 
complete details on how to obtain the publications they sell.

B. Regulations and Notices

    Regulations and notices are published in the daily Federal 
Register. Interested individuals may purchase individual copies or 
subscribe to the Federal Register by contacting the GPO at the address 
indicated above. When ordering individual copies, it is necessary to 
cite either the date of publication or the volume number and page 
number.

C. Rulings

    Rulings are published on an infrequent basis by HCFA. Interested 
individuals can obtain copies from the nearest HCFA Regional Office or 
review them at the nearest regional depository library. We also 
sometimes publish Rulings in the Federal Register.

D. HCFA's Compact Disk-Read Only Memory (CD-ROM)

    HCFA's laws, regulations, and manuals are now available on CD-ROM, 
which may be purchased from GPO or NTIS on a subscription or single 
copy basis. The Superintendent of Documents list ID is HCLRM, and the 
stock number is 717-139-00000-3. The following material is contained on 
the CD-ROM disk:
    <bullet> Titles XI, XVIII, and XIX of the Act.
    <bullet> HCFA-related regulations.
    <bullet> HCFA manuals and monthly revisions.
    <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 2--
Program Administration (HCFA-Pub. 14-2) transmittal entitled ``Files 
Maintenance Program General'', use the Superintendent of Documents No. 
HE 22.8/6-2 and the HCFA transmittal number 127.

VI. General Information

    It is possible that an interested party may have a specific 
information need and not be able to determine from the listed 
information whether the issuance or regulation would fulfill that need. 
Consequently, we are providing information contact persons to answer 
general questions concerning these items. Copies are not available 
through the contact persons. Copies can be purchased or reviewed as 
noted above.
    Questions concerning Medicare items in Addenda III may be addressed 
to Margaret Cotton, Issuances Staff, Bureau of Program Operations, 
Health Care Financing Administration, Room 688 East High Rise, 6325 
Security Blvd., Baltimore, MD 21207, Telephone (410) 966-5255.
    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 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: March 23, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.

Addendum I

    This addendum lists the publication dates of the most recent 
quarterly listing of program issuances and coverage decision updates to 
the Coverage Issues Manual. For a complete listing, please refer to the 
listing in the January 3, 1995 quarterly notice (60 FR 132).

March 17, 1994 (59 FR 12610)
August 5, 1994 (59 FR 40038)
November 14, 1994 (59 FR 56501)
January 3, 1995 (60 FR 132)

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.

                                                                        
[[Page 17541]]                                                          
        Addendum III.--Medicare and Medicaid Manual Instructions        
                     [October Through December 1994]                    
------------------------------------------------------------------------
 Trans. No.                   Manual/Subject/Publication Number         
------------------------------------------------------------------------
                           Intermediary Manual                          
                      Part 2--Audits, Reimbursement                     
                 Program Administration (HCFA-Pub. 13-2)                
              (Superintendent of Documents No. HE 22.8/6-1)             
                                                                        
------------------------------------------------------------------------
400           <bull  Files Maintenance Program--General.                
                 e                                                      
                     Records Retention and Disposal Schedule.           
                     Retention of Claims Files Materials.               
                     Microfilming of Files Material.                    
                     Intermediary--Federal Records Center Relations.    
                     Location of Federal Records Centers.               
                     Procedures for Transfer of Material to Federal     
                      Records Centers.                                  
                     Requesting Forms for Transfer and Return of        
                      Material from Federal Records Centers.            
                     Report of Medicare Records--Form HCFA-2556.        
                     Exhibits.                                          
401           <bull  Location of Federal Records Centers.               
                 e                                                      
                                                                        
------------------------------------------------------------------------
                           Intermediary Manual                          
                   Part 3--Claims Process (HCFA-13-3)                   
               (Superintendent of Documents No. HE 22.8/6)              
                                                                        
------------------------------------------------------------------------
1636          <bull  Responsibility for Medicare Secondary Payer        
                 e    Outreach Program.                                 
                     Quarterly Supplement to Intermediary Workload      
                      Report (Form HCFA-1566A) General.                 
                     Completing Quarterly Supplement to the Intermediary
                      Workload Report, HCFA-1566A, Pages 1 and 2.       
                     Completing Quarterly Supplement to the Intermediary
                      Workload Report, HCFA-1566A, Page 3.              
                     Completing Quarterly Periodic Interim Payment      
                      Report, HCFA-1566C--General.                      
1637          <bull  Reporting Outpatient Surgery and Other Services.   
                 e                                                      
                     PPS Pricer Program.                                
                     Provider-Specific Data Record Layout and           
                      Description.                                      
1638          <bull  Mammography Screening.                             
                 e                                                      
                     Mammography Quality Standards Act.                 
1639          <bull  Disallowance Form Letters HCFA-1954 and HCFA-1955. 
                 e                                                      
                     Explanation of Medicare Benefits Notice            
                      Specifications.                                   
1640          <bull  General Effect of Liability Insurance on Medicare  
                 e    Payment.                                          
                     Appeals Procedures for MSP Liability Overpayments. 
1641          <bull  Mammography Screening.                             
                 e                                                      
                                                                        
------------------------------------------------------------------------
                             Carriers Manual                            
               Part 2--Program Administration (HCFA-14-2)               
              (Superintendent of Documents No. HE 22.8/6-2)             
                                                                        
------------------------------------------------------------------------
127           <bull  Files Maintenance Program--General.                
                 e                                                      
                     Records Retention and Disposal Schedule.           
                     Retention of Claims Files Materials.               
                     Microfilming of Files Materials.                   
                     Report of Medicare Records--Form HCFA-2556.        
                     Location of Federal Records Centers.               
                     Procedures for Transfer of Material to Federal     
                      Records Centers.                                  
                     Requesting Forms for Transfer and Return of        
                      Material from Federal Records Centers.            
                     Exhibits.                                          
128           <bull  Location of Federal Records Centers.               
                 e                                                      
                                                                        
------------------------------------------------------------------------
                             Carriers Manual                            
             Part 4--Professional Relations (HCFA-Pub. 14-4)            
              (Superintendent of Documents No. HE 22.8/7-4)             
                                                                        
------------------------------------------------------------------------
9             <bull  Responsibility in the Medicare Secondary Payer     
                 e    Outreach Program.                                 
10            <bull  National Registry of Physicians/Health Care        
                 e    Practitioners/Group Practices-Medicare Provider   
                      Identifier (UPIN).                                
                     Ongoing Data Collection On Physicians/Health Care  
                      Practitioners/Group Applications.                 
                     Physicians/Health Care Practitioners/Group         
                      Practices Record-Required Information and Format. 
                     Maintaining Physicians/Health Care Practitioner/   
                      Group Practice Membership.                        
                     Validation of Physicians/Health Care Practitioners/
                      Group Practices Credentials, Certifications,      
                      Sanction and License Information for Prior        
                      Practice.                                         
              <bull  UPIN Cross Referral Requirement.                   
                 e                                                      
                     Maintenance of The Registry.                       
                     Update Records.                                    
                     Rejections.                                        
                     Exceptions.                                        
                     Carrier Record Requirements.                       
                     UPIN Carrier Record Layout.                        
[[Page 17542]]                                                          
                                                                        
                     List of Medical School Codes.                      
                                                                        
------------------------------------------------------------------------
                             Carriers Manual                            
                 Part 3--Claims Process (HCFA-Pub. 14-3)                
               (Superintendent of Documents No. HE 22.8/7)              
                                                                        
------------------------------------------------------------------------
1501          <bull  Quarterly Supplements to the Carrier Performance   
                 e    Report (Forms HCFA-1565A, HCFA-1565B, HCFA-1565C, 
                      and HCFA-1565D)--General.                         
                     Completing Form HCFA-1565A.                        
                     Completion of Items on Form HCFA-1565A.            
                     Completing Medicare Fraud Unit Quarterly Workload  
                      Status Report, HCFA-1565B--General.               
                     Completing Form HCFA-1565C.                        
                     Completion of Items on Form HCFA-1565C.            
                     Completing Comprehensive Limiting Charge Compliance
                      Program Quarterly Report HCFA-1565D--General.     
                     Completing Medicare Fraud Unit Quarterly Status    
                      Report, Form HCFA-1565B.                          
                     Completing Carrier Limiting Charge Compliance      
                      Program Quarterly Report, Form HCFA-1565D.        
1502          <bull  Chiropractors.                                     
                 e                                                      
                     Manual Manipulation.                               
                     Verification of Chiropractor's Qualifications.     
1503          <bull  Part B Provider Access to Limited Eligibility Data.
                 e                                                      
                     Eligibility Data Available.                        
                     Contractor Implementation.                         
                     Data Format.                                       
                     Part B Eligibility Data Security Requirements.     
                     HCFA Standard Part B Eligibility Data Security     
                      Requirements.                                     
                     HCFA Standard Part B Eligibility Inquiry Flat File 
                      Specifications.                                   
                     HCFA Standard Part B Eligibility Response Flat File
                      Specifications.                                   
1504          <bull  Type of Service.                                   
                 e                                                      
1505          <bull  Self-Administering of Drug or Biological.          
                 e                                                      
1506          <bull  List of Covered Surgical Procedures.               
                 e                                                      
1507          <bull  Rebundling of CPT-4 Codes.                         
                 e                                                      
                                                                        
------------------------------------------------------------------------
                           Program Memorandum                           
                     Intermediaries (HCFA-Pub. 60A)                     
              (Superintendent of Documents No. HE 22.8/6-5)             
                                                                        
------------------------------------------------------------------------
A-94-8        <bull  Revised Wages Indexes for Ambulatory Surgical      
                 e    Centers--Pricer for 7.0 and 8.0.                  
A-94-9        <bull  FY 1995 Prospective Payment System and Other Bill  
                 e    Processing Changes.                               
A-94-10       <bull  Ambulatory Surgical Center--Pricer 9.0.            
                 e                                                      
                                                                        
------------------------------------------------------------------------
                           Program Memorandum                           
                        Carriers (HCFA-Pub. 60B)                        
              (Superintendent of Documents No. HE 22.8/6-5)             
                                                                        
------------------------------------------------------------------------
B-94-6        <bull  1995 Physician, Practitioner and Supplier          
                 e    Participation Enrollment and Fee Schedule         
                      Disclosure.                                       
B-94-7        <bull  1995 Physician, Practitioner and Supplier          
                 e    Participation Enrollment and Fee Schedule         
                      Disclosure.                                       
B-94-8        <bull  Split Billing for Professional and Technical       
                 e    Components of Services.                           
                                                                        
------------------------------------------------------------------------
                            Program Memorandum                          
                Intermediaries/Carriers (HCFA-Pub. 60AB)                
              (Superintendent of Documents No. HE 22.8/6-5)             
                                                                        
------------------------------------------------------------------------
AB-94-8       <bull  Revised Codes for Part B Ground Ambulance Services.
                 e                                                      
                                                                        
------------------------------------------------------------------------
                           Program Memorandum                           
                 Medicaid State Agencies (HCFA-Pub. 17)                 
              (Superintendent of Documents No. HE 22.8/6-5)             
                                                                        
------------------------------------------------------------------------
94-8          <bull  Title XIX, Social Security Act, Vaccines for       
                 e    Children Program.                                 
94-9          <bull  Title XIX, Social Security Act, Personal Care      
                 e    Services Provided in a Home or Other Location.    
                                                                        
------------------------------------------------------------------------
                         Regional Office Manual                         
              Standards and Certification (HCFA-Pub. 23-4)              
            (Superintendent of Documents No. HE 22.28/5:90-1)           
                                                                        
------------------------------------------------------------------------
55            <bull  Developing the Budget Approval.                    
                 e                                                      
                     Submittal of Budget Approval.                      
                     Distribution of Approved Funds.                    
                     Disbursement of Authorized Funds.                  
[[Page 17543]]                                                          
                                                                        
                     The Budget Call.                                   
                     Monitoring State Agency Fiscal Budgets.            
56            <bull  Approval Procedures for Hospitals in the 50-99 Bed 
                 e    Category.                                         
                                                                        
------------------------------------------------------------------------
                     Peer Review Organization Manual                    
                             (HCFA-Pub. 19)                             
              (Superintendent of Documents No. HE 22.8/15)              
                                                                        
------------------------------------------------------------------------
40            <bull  Introduction.                                      
                 e                                                      
                     MOA with State Agencies Responsible for Licensing/ 
                      Certification of Providers/Practitioners.         
                     Model Memorandum of Agreement.                     
41            <bull  Complaints to be Reviewed.                         
                 e                                                      
                     Disposition of Complaints.                         
                     Disclosing Information.                            
                     Monitoring Hospital-Issued Notices of Noncoverage. 
                     Beneficiary Liability.                             
                     Model Hospital-Issued Notice of Noncoverage        
                      Continued Stay--Swing Bed Only.                   
42            <bull  DRG Validation Review.                             
                 e                                                      
43            <bull  Training.                                          
                 e                                                      
                                                                        
------------------------------------------------------------------------
                             Hospital Manual                            
                             (HCFA-Pub. 10)                             
               (Superintendent of Documents No. HE 22.8/2)              
                                                                        
------------------------------------------------------------------------
673           <bull  Billing for Mammography Screening.                 
                 e                                                      
                     Mammography Quality Standards Act.                 
674           <bull  Billing for Mammography Screening.                 
                 e                                                      
                                                                        
------------------------------------------------------------------------
                        Skilled Nursing Facility                        
                             (HCFA-Pub. 12)                             
               (Superintendent of Documents No. HE 22.8/3)              
                                                                        
------------------------------------------------------------------------
332           <bull  Billing for Mammography Screening.                 
                 e                                                      
                     Mammography Quality Standards Act.                 
333           <bull  Billing for Mammography Screening.                 
                 e                                                      
                                                                        
------------------------------------------------------------------------
                          State Medicaid Manual                         
                  Part 3--Eligibility (HCFA-Pub. 45-3)                  
              (Superintendent of Documents No. HE 22.8/10)              
                                                                        
------------------------------------------------------------------------
64            <bull  Transfers of Assets for Less Than Fair Market      
                 e    Value.                                            
                     Treatment of Trusts.                               
                                                                        
------------------------------------------------------------------------
                          State Medicaid Manual                         
              Part 6--Payment for Services (HCFA-Pub. 45-6)             
              (Superintendent of Documents No. HE 22.8/10)              
                                                                        
------------------------------------------------------------------------
26            <bull  Listing of Multiple Source Drugs.                  
                 e                                                      
                                                                        
------------------------------------------------------------------------
                          State Medicaid Manual                         
                Part 7--Quality Control (HCFA-Pub. 45-7)                
              (Superintendent of Documents No. HE 22.8/10)              
                                                                        
------------------------------------------------------------------------
52            <bull  Computations of Financial Eligibility.             
                 e                                                      
                     Verification Guide--Coverage Code 02 for OASDI     
                      Recipients.                                       
                     Verification Guide--Coverage Code 01 or 03.        
                     Verification Guide--Coverage Code 18 for QDWI      
                      Individuals.                                      
                     Verification Guide--Coverage Code 25 for           
                      Individuals Whose Eligibility for Medicaid Has    
                      Otherwise Ceased.                                 
                     Verification Guide--Coverage Code 26 for           
                      Individuals Whose Eligibility for Medicaid Has    
                      Otherwise Ceased.                                 
                     Verification Guide--Coverage Code 29 for           
                      Individuals Receiving Home and Community-Based    
                      Services and Other Waiver Services.               
                     Verification Guide--Coverage Code 31.              
                     Verification Guide--Coverage Code 40 for AFDC      
                      Families.                                         
                                                                        
------------------------------------------------------------------------
                         Coverage Issues Manual                         
                              (HCFA-Pub. 6)                             
              (Superintendent of Documents No. HE 22.8/14)              
                                                                        
------------------------------------------------------------------------
72            <bull  Blood Transfusions.                                
                 e                                                      
[[Page 17544]]                                                          
                                                                        
73            <bull  Hydrophilic Contact Lens for Corneal Bandage.      
                 e                                                      
                                                                        
------------------------------------------------------------------------
                        Home Health Agency Manual                       
                             (HCFA-Pub. 11)                             
               (Superintendent of Documents No. HE 22.8/5)              
                                                                        
------------------------------------------------------------------------
273           <bull  Home Health Certification and Plan of Care.        
                 e                                                      
                                                                        
------------------------------------------------------------------------
                         State Operations Manual                        
                  Provider Certification (HCFA-Pub. 7)                  
              (Superintendent of Documents No. HE 22.8/12)              
                                                                        
------------------------------------------------------------------------
265           <bull  Hospice Regulations and Non-Medicare Patients.     
                 e                                                      
                     Operation of a Hospice Across State Lines.         
                     Compliance with Advance Directives.                
                     Hospice--Citations and Description.                
                     Hospice Multiple Locations.                        
                     Election of Hospice Benefit by Resident of a       
                      Skilled Nursing Facility, Nursing Facility,       
                      Intermediate Care Facility for the Mentally       
                      Retarded, or Non-Certified Facility.              
                     Hospice Inpatient Services Furnished Directly or   
                      Furnished Under Arrangements.                     
                     Hospice Home Visit Procedures.                     
                     Model Consent for Hospice Home Visit Form.         
                     Hospice Survey and Deficiencies Report.            
                     Interpretive Guidelines--Hospices.                 
                                                                        
------------------------------------------------------------------------
                    Rural Health Clinic and Federally                   
             Qualified Health Centers Manual (HCFA-Pub. 27)             
            (Superintendent of Documents No. HE 22.8/19:985)            
                                                                        
------------------------------------------------------------------------
16            <bull  Billing for Mammography Screening by Rural Health  
                 e    Clinic and Federally Qualified Health Centers.    
                     Mammography Qualified Standards Act.               
17            <bull  Billing for Mammography Screening by Rural Health  
                 e    Clinics and Federally Qualified Health Centers.   
                                                                        
------------------------------------------------------------------------
                            Medicare/Medicaid                           
                     Sanction--Reinstatement Report                     
                                                                        
------------------------------------------------------------------------
94-13         <bull  Report of Physician/Practitioners, Providers and/or
                 e    Other Health Care Suppliers Excluded/Reinstated.  
94-14         <bull  Report of Physician/Practitioners, Providers and/or
                 e    Other Health Care Suppliers Excluded/Reinstated.  
------------------------------------------------------------------------

Addendum IV--Medicare Coverage Issues Manual

(For the reader's convenience, new material and changes to previously 
published material are in italics. If any part of a sentence in the 
manual instruction has changed, the entire line is shown in italics. 
The transmittal includes material unrelated to revised sections. We are 
not reprinting the unrelated material.)

    Transmittal No. 72; section 45-27 Blood Transfusions NEW 
INPLEMENTING INSTRUCTIONS--EFFECTIVE DATE: For services performed on or 
after 12-08-94.
    Section 45-27, Blood Transfusions.--This section has been added to 
clarify the coverage and payment policies for blood transfusions.
45-27  BLOOD TRANSFUSIONS
    Blood transfusions are used to restore blood volume after 
hemorrhage, to improve the oxygen carrying capacity of blood in severe 
anemia, and to combat shock in acute hemolytic anemia.
    A. Definitions.--
    1. Homologous Blood Transfusion.--Homologous blood transfusion is 
the infusion of blood or blood components that have been collected from 
the general public.
    2. Autologous Blood Transfusion.--An autologous blood transfusion 
is the precollection and subsequent infusion of a patient's own blood.
    3. Donor Directed Blood Transfusion.--A donor directed blood 
transfusion is the infusion of blood or blood components that have been 
precollected from a specific individual(s) other than the patient and 
subsequently infused into the specific patient for whom the blood is 
designated. For example, patient B's brother predeposits his blood for 
use by patient B during upcoming surgery.
    4. Perioperative Blood Salvage.--Perioperative blood salvage is the 
collection and reinfusion of blood lost during and immediately after 
surgery.
    B. Policy Governing Transfusions.--For Medicare coverage purposes, 
it is important to distinguish between a transfusion itself and 
preoperative blood services; e.g., collection, processing, storage. 
Medically necessary transfusion of blood, regardless of the type, may 
generally be a covered service under both Part A and Part B of 
Medicare. Coverage does not make a distinction between the transfusion 
of homologous, autologous, or donor-directed blood. With respect to the 
coverage of the services associated with the preoperative collection, 
processing, and storage of autologous and donor-directed blood, the 
following policies apply.
    1. Hospital Part A and B Coverage and Payment.--Under 
Sec. 1862(a)(14) of the Act, nonphysician services furnished to 
hospital patients are covered and paid for as hospital services. The 
inclusion of services [[Page 17545]] provided to hospital patients by 
an outside supplier as part of hospital services is referred to as 
``bundling.'' In a situation where a hospital obtains either autologous 
or donor-directed blood from an independent supplier, the supplier 
collects, processes, and stores the blood and, typically, delivers it 
to the hospital. The hospital is responsible for paying the supplier.
    Part A payment, as specified in Sec. 1814(b) of the Act, and Part B 
payment, as specified in Sec. 1833(a) of the Act, relate to reasonable 
cost as defined in Sec. 1861(v) of the Act. Under this system, when a 
hospital obtains autologous or donor-directed blood from an independent 
blood bank, Medicare recognizes only a processing fee charged to the 
hospital by the independent blood bank because the blood has been 
replaced, albeit in advance. The processing fee is recorded by the 
hospital in the blood storing, processing, and transfusion cost center. 
This cost center also includes any costs the hospital itself incurs to 
process and administer the blood after it has been procured. This 
includes the cost of such activities as storing, type crossmatching, 
and transfusing the blood, as well as the cost of spoiled or defective 
blood. The hospital may generate a charge for these costs (except for 
spoiled or defective blood) and, under cost reimbursement, Medicare 
picks up its share of the costs through cost apportionment. As provided 
in Sec. 1886 of the Act, under the prospective payment system (PPS), 
the diagnosis related group (DRG) payment to the hospital includes all 
covered blood and blood processing expenses, whether or not the blood 
is eventually used.
    In a situation where the hospital operates its own blood collection 
activities, rather than using an independent blood supplier, the costs 
incurred to collect autologous or donor-directed blood are recorded in 
the whole blood and packed red blood cells cost center. Because the 
blood has been replaced, Medicare does not recognize a charge for the 
blood itself. Therefore, under cost reimbursement, these costs are 
shared by all patients through cost apportionment. The costs incurred 
by the hospital to store, process, and transfuse the blood, as well as 
the cost of spoiled or defective blood, are recorded in the blood 
storing, processing, and transfusion cost center. The hospital may 
generate a charge for these costs (except for the cost of spoiled or 
defective blood) and, under cost reimbursement, Medicare picks up its 
share of these costs through cost apportionment. Under PPS, the DRG 
payment is intended to pay for all covered blood and blood services, 
whether or not the blood is eventually used.
    Under its provider agreement, a hospital is required to furnish or 
arrange for all covered services furnished to hospital patients. 
Medicare payment is made to the hospital, under PPS or cost 
reimbursement, for covered inpatient and outpatient services, and it is 
intended to reflect payment for all costs of furnishing those services.
    2. Nonhospital Part B Coverage.--Under Part B, to be eligible for 
separate coverage, a service must fit the definition of one of the 
services authorized by Sec. 1832 of the Act. These services are defined 
in 42 CFR 410.10 and do not include a separate category for a 
supplier's services associated with blood donation services, either 
autologous or donor-directed. That is, the collection, processing, and 
storage of blood for later transfusion into the beneficiary is not 
recognized as a separate service under Part B. Therefore, there is no 
avenue through which a blood supplier can receive direct payment under 
Part B for blood donation services.
    C. Perioperative Blood Salvage.--When the perioperative blood 
salvage process is used in surgery on a hospital patient, payment made 
to the hospital (under PPS or through cost reimbursement) for the 
procedure in which that process is used is intended to encompass 
payment for all costs relating to that process.
    Transmittal No. 73; Section 45-7, Hydrophilic Contact Lens for 
Corneal Bandage. CLARIFICATION--EFFECTIVE DATE: Not Applicable.
    Section 45-7, Hydrophilic Contact Lens for Corneal Bandage.--This 
section has been revised to explain how payment is provided for 
hydrophilic contact lenses when they are furnished incident to a 
physician's services. Payment for the lenses is bundled into the 
payment for the physician service to which it is incident. If the 
lenses are covered as other than incident to a physician's service, 
they are not paid under the physicians' fee schedule and would be 
covered prosthetic devices, which follow other payment provisions of 
the Act.
45-7  HYDROPHILIC CONTACT LENS FOR CORNEAL BANDAGE
    Some hydrophilic contact lenses are used as moist corneal bandages 
for the treatment of acute or chronic corneal pathology, such as 
bullous keratopathy, dry eyes, corneal ulcers and erosion, keratitis, 
corneal edema, descemetocele, corneal ectasis, Mooren's ulcer, anterior 
corneal dystrophy, neurotrophic keratoconjunctivitis, and for other 
therapeutic reasons.
    Payment may be made under Sec. 1861(s)(2) of the Act for a 
hydrophilic contact lens approved by the Food and Drug Administration 
(FDA) and used as a supply incident to a physician's service. Payment 
for the lens is included in the payment for the physician's service to 
which the lens is incident. Contractors are authorized to accept an FDA 
letter of approval or other FDA published material as evidence of FDA 
approval. (See Sec. 65-1 for coverage of a hydrophilic contact lens as 
a prosthetic device.) See Intermediary Manual, Sec. 3112.4 and Carriers 
Manual, Secs. 2050.1 and 15010.

                                           Addendum V.--Regulation Documents Published in the Federal Register                                          
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                                                                                                                                   End of               
  Publication date     FR page numbers      CFR part             File code*                      Regulation title                 comment     Effective 
                                                                                                                                   period        date   
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10/03/94............       50235-50240  ................  MB-084-NC                 Medicaid Program; Charges for Vaccine       ...........     10/01/94
                                                                                     Administration Under the Vaccines for                              
                                                                                     Children (VFC) Program.                                            
10/03/94............       50246-50253  ................  ORD-068-N                 Medicare and Medicaid Programs; Small       ...........     10/03/94
                                                                                     Business Innovation Research Grants for                            
                                                                                     Fiscal Year 1995.                                                  
10/07/94............       51125-51130               403  OBS-001-FC                Medicare Program; Information, Counseling,     12/06/94    10/07/94 
                                                                                     and Assistance Grants Program.                                     
[[Page 17546]]                                                                                                                                          
                                                                                                                                                        
10/13/94............             51989  ................  MB-084-CN                 Medicaid Program; Charges for Vaccine          12/12/94     10/01/94
                                                                                     Administration Under the Vaccines for                              
                                                                                     Children (VFC) Program Correction.                                 
10/14/94............       52129-52132               418  BPD-820-N                 Hospice Services Under Medicare Program;       11/14/94     10/14/94
                                                                                     Intent To Form Negotiated Rulemaking                               
                                                                                     Committee.                                                         
10/19/94............             52862           488 489  BPD-393-IFC               Medicare Program; Participation in CHAMPUS     08/22/94     07/22/94
                                                                                     and CHAMPVA, Hospital Admissions for                               
                                                                                     Veterans, Discharge Rights Notice, and                             
                                                                                     Hospital Responsibility for Emergency                              
                                                                                     Care OFR Correction.                                               
10/20/94............       52968-52971  ................  HSQ-220-N                 CLIA Program; Approval of the American      ...........     10/20/94
                                                                                     Society for Histocompatibility and                                 
                                                                                     Immunogenetics for the Specialty of                                
                                                                                     Histocompatibility.                                                
10/20/94............       52971-52972  ................  OPL-002-N                 Medicare Program; Request for Nominations   ...........     10/20/94
                                                                                     for Members for the Practicing Physicians                          
                                                                                     Advisory Council.                                                  
10/21/94............       53187-53193  ................  BPO-124-PN                Medicare Program; Data, Standards, and         12/20/94  ...........
                                                                                     Methodology Used to Establish Fiscal Year                          
                                                                                     1995 Budgets for Fiscal Intermediaries                             
                                                                                     and Carriers.                                                      
11/10/94............       56116-56252       401 431 435  HSQ-156-F                 Medicare and Medicaid Programs, Survey,     ...........     07/01/95
                                             440 441 442                             Certification and Enforcement of Skilled                           
                                             447 483 488                             Nursing Facilities and Nursing Facilities.                         
                                                 489 498                                                                                                
11/14/94............       56501-56510  ................  BPO-127-N                 Medicare and Medicaid Programs; Quarterly   ...........     11/14/94
                                                                                     Listing of Program Issuances and Covered                           
                                                                                     Decisions-Second Quarter 1994.                                     
11/16/94............       59241-61629  ................  BPO-128-N                 Medicare and Medicaid Programs; Delay in    ...........     11/16/94
                                                                                     Implementation of the Medicare-Medicaid                            
                                                                                     Coverage Data Bank Requirements.                                   
11/17/94............             59624  ................  MB-060-P                  Medicaid Program; Inpatient Psychiatric        01/17/94  ...........
                                                                                     Services for Individuals Under Age 21.                             
11/21/94............       59933-59943               417  OMC-008-F                 Medicare Program; Appeal Rights and         ...........     12/21/94
                                                                                     Procedures for Beneficiaries Enrolled in                           
                                                                                     Prepaid Health Care Plans.                                         
11/22/94............       60109-60156               205  MB-092-P                  Aid to Families With Dependent Children;       01/23/95  ...........
                                                                                     National Voter Registration Act of 1993;                           
                                                                                     Implementation.                                                    
11/23/94............             60365  ................  OPL-003-N                 Medicare Program; Meeting of the            ...........     11/23/94
                                                                                     Practicing Physicians Advisory Council.                            
12/01/94............       61629-61628  ................  OACT-046-N                Medicare Program; Part A Premium for 1995   ...........     01/01/95
                                                                                     for the Uninsured Aged and for Certain                             
                                                                                     Disabled Individuals Who Have Exhausted                            
                                                                                     Other Entitlement.                                                 
12/01/94............       61629-61633  ................  OACT-047-N                Medicare Program; Monthly Actuarial Rates   ...........     01/01/95
                                                                                     and Monthly Supplementary Medical                                  
                                                                                     Insurance Premium Rates Beginning January                          
                                                                                     1, 1995.                                                           
12/01/94............       61628-61633  ................  OACT-048-N                Medicare Program; Inpatient Hospital        ...........     01/01/95
                                                                                     Deductible and Hospital and Extended Care                          
                                                                                     Services Coinsurance Amounts for 1995.                             
[[Page 17547]]                                                                                                                                          
                                                                                                                                                        
12/06/94............       62606-62609               493  HSQ-217-FC                Medicare, Medicaid and CLIA Programs;          02/06/95     12/06/94
                                                                                     Extension of Certain Effective Dates for                           
                                                                                     Clinical Laboratory Requirements and                               
                                                                                     Personnel Requirements for Cytologists.                            
12/08/94............       63410-63635           410 414  BPD-789-FC                Medicare Program; Refinements to               02/06/95     01/01/95
                                                                                     Geographic Adjustment Factor Values,                               
                                                                                     Revisions to Payment Policies,                                     
                                                                                     Adjustments to the Relative Value Units                            
                                                                                     (RVUs) Under The Physician Fee Schedule                            
                                                                                     for Calender Year 1995, and the 5-Year                             
                                                                                     Refinement of RVUs.                                                
12/08/94............       63638-63646  ................  BPD-807-FN                Physician Fee Schedule Update for Calendar  ...........     01/01/95
                                                                                     Year 1995 and Physician Volume                                     
                                                                                     Performance Standard Rates of Increase                             
                                                                                     for Federal Fiscal Year 1995.                                      
12/13/94............       64141-64153           405 482  BPD-421-F                 Medicare and Medicaid Programs; Revisions   ...........     01/12/95
                                                                                     to Conditions of Participation for                                 
                                                                                     Hospitals.                                                         
12/13/94............       64153-64156           412 413  BPD-802-CN                Medicare Program; Changes to the Hospital   ...........     10/01/94
                                                                                     Inpatient Prospective Systems and Fiscal                           
                                                                                     Year 1995 Rates; Correction.                                       
12/20/94............       64482-65498       409 413 418  BPD-469-F                 Medicare Program; Medicare Coverage of      ...........     02/21/95
                                                     484                             Home Health Services, Medicare Conditions                          
                                                                                     of Participation, and Home Health Aide                             
                                                                                     Supervision.                                                       
12/23/94............       66314-66316  ................  HSQ-221-N                 Medicare, Medicaid, and CLIA Programs;      ...........     12/29/94
                                                                                     Clinical Laboratory Improvement                                    
                                                                                     Amendments of 1988 Continuance of                                  
                                                                                     Exemption of Laboratories Licensed by the                          
                                                                                     State of Washington.                                               
12/29/94............       67264-67265  ................  BPD-822-N                 Medicare Program; Hospice Wage Index......  ...........     12/29/94
12/29/94............             67265  ................  BPD-823-N                 Medicare Program; Hospice Wage Index......  ...........    12/29/94 
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*GN--General Notice; PN--Proposed Notice; FN--Final Notice; P--Notice of Proposed Rulemaking (NPRM); F--Final Rule; FC--Final Rule with Comment Period; 
  CN--Correction Notice; SN--Suspension Notice; WN--Withdrawal Notice; NR--Notice of HCFA Ruling.                                                       

[FR Doc. 95-8398 Filed 4-5-95; 8:45 am]
BILLING CODE 4120-01-P