(a) The department
will pay an in-state physician for surgical procedures in accordance with the
physician payment rates determined under
7
AAC 145.050, subject to the following exceptions:
(1) the highest-valued procedure of multiple
surgeries performed on the same recipient during the same operative session or
on the same day will be paid at 100 percent of the rate determined under
7
AAC 145.050, and each additional surgery at 50 percent
of the rate determined under
7
AAC 145.050;
(2) bilateral surgeries will be paid at the
lesser of billed charges or 150 percent of the rate determined under
7
AAC 145.050;
(3) co-surgeons will be paid for the same
surgical procedure, if medically necessary, by increasing the payment rate
determined under
7
AAC 145.050 by 25 percent and splitting the payment
equally between the surgeons;
(4)
intra-operative procedures only billed using modifier -54 from the list of
modifiers set out in
Current Procedural Terminology, adopted
by reference in
7
AAC 160.900, will be paid at the lesser of billed
charges or 80 percent of the rate determined under
7
AAC 145.050;
(5) pre-operative services that are performed
by a physician other than the surgeon, and that are billed using modifier -56
from the list of modifiers set out in
Current Procedural
Terminology, adopted by reference in
7
AAC 160.900, will be paid at the lesser of the billed
charges or 10 percent of the rate determined under
7
AAC 145.050;
(6) postoperative services that are performed
by a physician other than the surgeon, and that are billed using modifier -55
from the list of modifiers set out in
Current Procedural
Terminology, adopted by reference in
7
AAC 160.900, will be paid at the lesser of billed
charges or 10 percent of the rate determined under
7
AAC 145.050;
(7) supplies associated with surgical
procedures performed in a physician's office will be paid only when a surgical
procedure is approved for payment for the same date of service in the
physician's office; the department will pay the lesser of the billed charges or
the rate determined under
7
AAC 145.050(h).
(b) The department will pay a physician
acting as a surgical assistant the lesser of billed charges or 25 percent of
the rate determined under
7
AAC 145.050. The department will pay an advanced
practice registered nurse acting as a surgical assistant the lesser of billed
charges or 25 percent of the rates established for advanced practice registered
nurse under
7
AAC 145.100.
(c) The department will pay a physician for
the use of a physician assistant, acting as a surgical assistant, the lesser of
billed charges or at the same rate paid to an advanced practice registered
nurse as described in (b) of this section.
(d) The department will pay an out-of state
physician for surgical procedures in accordance with
7
AAC 145.025 and this section.
