§ 1150.54. Surgical services.
(a) Inpatient surgical services.
(1) A practitioner may bill for any covered surgical procedure performed on an inpatient basis unless the surgical procedure could appropriately and safely be performed on an outpatient basis in an office, clinic, emergency room or in a hospital short procedure unit.
(2) Those surgical procedures designated in the Medical Assistance Program Fee Schedule with an outpatient indicator (OP) are not compensable when performed on an inpatient basis unless the medical condition of the patient is such that to perform the procedure on an outpatient basis, including a short procedure unit, could result in undue risk to the life or health of the patient. Detailed documentation of the condition of risk to the life or health of the patient shall be included in the patient’s medical record and on the claim submitted for payment.
(3) An assistant surgeon may bill only for the surgical procedures designated in the Medical Assistance Program Fee Schedule with the assistant surgeon indicator. The maximum payment to the assistant surgeon will be an amount equal to 20% of the Medical Assistance maximum allowable payment made to the surgeon. See paragraph (4).
(4) The fee for an inpatient surgical procedure includes:
(i) Preoperative inpatient visits.
(ii) Inpatient and outpatient office or home visits provided by the practitioner who performed the procedure for a purpose related to surgery or surgical diagnosis during the number of postoperative days specified in the Medical Assistance Program Fee Schedule for each surgical procedure. During this specified period, the practitioner who performed the surgery is eligible to receive payment for treatment of a medical or surgical condition if the diagnosis necessitating the treatment is different and unrelated to the surgery.
(iii) The removal of sutures and casts.
(5) When two or more surgical procedures are performed by the same practitioner during the same period of hospitalization, the practitioner will be reimbursed at 100% for the highest allowable payment for one procedure and 25% for the second highest paying procedure, with no payment for additional procedures.
(6) A practitioner who performs a surgical procedure may also bill for medical diagnostic procedures, surgical diagnostic procedures, and radiation therapy for the same patient during the same period of hospitalization.
(7) Payment may be made to a practitioner who performs the surgical procedure and to one other practitioner who is responsible for the medical care of the same patient.
(b) Outpatient surgical procedures.
(1) The fee for an outpatient surgical procedure includes:
(i) Postoperative office and home visits provided by the practitioner who performed the procedure for a purpose related to the surgery or surgical diagnosis during the number of postoperative days specified in the Medical Assistance Program Fee Schedule for each surgical procedure. During this specified period, the practitioner who performed the surgery is eligible to receive payment for treatment of a medical or surgical condition if the diagnosis necessitating the treatment is different and unrelated to the surgery.
(ii) The removal of sutures and casts.
(2) When two or more surgical procedures are performed by the same practitioner on the same day, the practitioner will be reimbursed at 100% for the highest allowable payment for one procedure and 25% for the second highest paying procedure, with no payment for additional procedures.
(3) Payment is made for services performed in an approved short procedure unit 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.
Source The provisions of this § 1150.54 adopted January 7, 1983, effective January 1, 1983, 13 Pa.B. 305; amended September 7, 1984, effective July 1, 1984, 14 Pa.B. 3252; amended September 30, 1988, effective October 1, 1988, 18 Pa.B. 4418. Immediately preceding text appears at serial pages (93508) and (96131).
Cross References This section cited in 55 Pa. Code § 1149.52 (relating to payment conditions for various dental services).
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