change statement

Justification for changes to the Portable X-Ray Survey Report (Form CMS-1882)
CMS is seeking to make a minor change to the Portable X-Ray Survey Report (OMB 0938-0027). This
technical change is considered to be a minor non-substantive change to update a survey tool utilized by
State survey agencies on behalf of CMS. This change does not impact any burden estimates.
The survey report form (CMS-1882) is an instrument used by a State survey agency to assess a portable
x-ray supplier’s compliance with the applicable Medicare conditions for coverage and report this
information to the Federal Government. The form is completed by State surveyors when surveying
portable x-ray suppliers. The form is primarily a standardized coding worksheet designed to facilitate
data entry into a dataset utilized by CMS. The form includes basic information on compliance (i.e., met,
not met, explanatory statements) with the Medicare conditions.
A change in the conditions for coverage for portable x-ray services permitted nonphysician practitioners
to order portable x-ray services. This change was published as part of the 2013 physicians fee schedule
and other revisions to part B (77 FR 68891) on November 16, 2012. We are requesting to update to the
language on the survey report form to conform with the change in the Medicare requirement.