§ 1126.53. Limitations on covered procedures.
(a) Payment will be made for same day surgical procedures listed by the department as compensable when provided under § 1126.1 (relating to policy).
(b) Payment for procedures that are appropriate for same day surgery but are not yet included in the established list of covered ASC/SPU services is limited to:
(1) The specific fee for each procedure developed by the Department when enough data is obtained to establish a fee.
(2) Prior to establishment of a fee, the Statewide average cost of same day surgery developed by the Department.
(c) Payment will be made for services performed in an approved ASC/SPU only if the service could not be appropriately and safely performed in the practitioner’s office, the clinic or the emergency room of a hospital, because the medical needs of the patient require less than 24-hour care, and the use of inpatient hospital resources, especially an operating room, and in some cases administration of general anesthesia.
Cross References This section cited in 55 Pa. Code § 1126.41 (relating to participation requirements).
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