[Federal Register Volume 62, Number 236 (Tuesday, December 9, 1997)]
[Notices]
[Pages 64851-64852]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-32100]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Care Financing Administration
[Document Identifier: HCFA-484]


Agency Information Collection Activities: Submission for OMB 
Review; Comment Request

    In compliance with the requirement of section 3506(c)(2)(A) of the 
Paperwork Reduction Act of 1995, the Health Care Financing 
Administration (HCFA), Department of Health and Human Services, has 
submitted to the Office of Management and Budget (OMB) the following 
proposal for the collection of information. Interested persons are 
invited to send comments regarding the burden estimate or any other 
aspect of this collection of information, including any of the 
following subjects: (1) The necessity and utility of the proposed 
information collection for the proper performance of the agency's 
functions; (2) the accuracy of the estimated burden; (3) ways to 
enhance the quality, utility, and clarity of the information to be 
collected; and (4) the use of automated collection techniques or other 
forms of information technology to minimize the information collection 
burden.
    Type of Information Collection Request: Extension of a currently 
approved collection without change; Title of Information Collection: 
Attending Physician's Certification of Medical Necessity for Home 
Oxygen Therapy and Supporting Regulations 42 CFR 410.38 and 42 CFR 
424.5; Form Number: HCFA-484 (OMB approval #0938-0534); Use: To 
determine oxygen is reasonable and necessary pursuant to Medicare 
Statute, Medicare claims for home oxygen therapy must be supported by 
the treating physician's statement and other information including 
estimate length of need (# of months), diagnosis codes (ICD-9) and:
    1. Results and date of the most recent arterial blood gas 
PO2 and/or oxygen saturation tests.
    2. The most recent arterial blood gas PO2 and/or oxygen 
saturation test performed EITHER with the patient in a chronic stable 
state as an outpatient, OR

[[Page 64852]]

within two days prior to discharge from an inpatient facility to home.
    3. The most recent arterial blood gas PO2 and/or oxygen 
saturation test performed at rest, during exercise, or during sleep.
    4. Name and address of the physician/provider performing the most 
recent arterial blood gas PO2 and/or oxygen saturation test.
    5. If ordering portable oxygen, information regarding the patient's 
mobility within the home.
    6. Identification of the highest oxygen flow rate (in liters per 
minute) prescribed.
    7. If the prescribed liters per minute (LPM), as identified in item 
6, are greater than 4 LPM, provide the results and date of the most 
recent arterial blood gas PO2 and/or oxygen saturation test 
taken on 4 LPM.
    If the PO2 = 56-59, or the oxygen saturation = 89%, then 
evidence of the beneficiary meeting at least one of the following 
criteria must be provided.
    8. The patient having dependent edema due to congestive heart 
failure.
    9. The patient having cor pulmonale or pulmonary hypertension, as 
documented by P pulmonale on an EKG or by an echocardiogram, gated 
blood pool scan or direct pulmonary artery pressure measurement.
    10. The patient having a hematocrit greater than 56%.
    Form HCFA-484 obtains all pertinent information and promotes 
national consistency in coverage determinations; Frequency: Other (as 
needed); Affected Public: Individuals/households, business or other for 
profit, and not for profit institutions; Number of Respondents: 
300,000; Total Annual Responses: 300,000; Total Annual Hours Requested: 
50,000.
    To obtain copies of the supporting statement, and any related forms 
referenced above, E-mail your request, including your address and phone 
number, to P[email protected], or call the Reports Clearance Office on 
(410) 786-1326. Written comments and recommendations for the proposed 
information collections must be mailed within 30 days of this notice 
directly to the OMB Desk Officer designated at the following address: 
OMB Human Resources and Housing Branch, Attention: Allison Eydt, New 
Executive Office Building, Room 10235, Washington, D.C. 20503.

    Dated: December 2, 1997.
John P. Burke III,
HCFA Reports Clearance Officer, HCFA, Office of Information Services, 
Information Technology Investment Management Group, Division of HCFA 
Enterprise Standards.
[FR Doc. 97-32100 Filed 12-8-97; 8:45 am]
BILLING CODE 4120-03-P