Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 27 - Utilization Review Procedures
Section I-2713 - Ambulatory Surgery

Universal Citation: LA Admin Code I-2713

Current through Register Vol. 50, No. 9, September 20, 2024

A. Ambulatory surgery refers to a program which recommends that specified surgical procedures be performed on an outpatient basis. The program is designed to reduce unnecessary hospitalizations and to shift care to less costly settings if medically appropriate. The surgeon is responsible for following the specified guidelines for procedures which should be performed in an outpatient setting.

B. Ambulatory Surgery Procedures

1. The following is a list of surgical procedures and tests that are classified as primarily outpatient procedures not requiring hospitalization under normal circumstances.

Arthroscopy

Brush Biopsy of Stomach

Blood Transfusions

Carpal Tunnel Release

Closed Reduction Nasal Fracture

Cystoscopy

Closed Reduction of Dislocation or Fracture

Dx Radiological Procedures in Absence of Acute Admittable Illness

Dx Ultrasound

Esophagoscopy

Exploration Tendon Sheath-Hand

Excision Lesion Tendon Sheath-Hand

Excision Lesion Tendon Sheath

Fiberoptic Bronchoscopy

Flex Fiberoptic Colonoscopy

Gastroscopy

Lid Reconstruction

Laryngoscopy/ Tracheoscopy

Large Bowel Endoscopy

Laparoscopy

Other Larynx Diagnostic Procedures

Other Fusion of Toe

Other Skin and Subcutaneous Incision/Drainage

Other Local Destruction of Skin

Peripheral Nerve Biopsy

Plastic Repair External Ear

Partial Ostectomy

Sinus Puncture for Lavage

Surgical Tooth Extraction

Small Bowel Endoscopy-via existing surgical ostomy

Skin Incision and Foreign Body Removal

Skin and Subcutaneous Biopsy

Skin Suture

Tooth Extraction

Turbinate Fracture

Tenotomy of Hand

Total Ostectomy-Digit

Turbinectomy by Diathermy/Cryosurgery

The Office of Workers' Compensation may expand this list pursuant to its rulemaking authority.

2. The carrier/self-insured employer should not waive ambulatory surgeries except on the basis of defined criteria, which must include at least the following:
a. presence of other documented medical problems that make prolonged pre-operative or post-operative observation medically necessary;

b. inability to provide proper post-operative care at home; and

c. likelihood that another major surgical procedure might follow the initial procedure.

3. The carrier/self-insured employer should have an automated system for administering program requirements and documenting provider compliance with the program.

C. Ambulatory Surgery Preparation

1. Preparation
a. It is important to stress to the provider that the intent of the program is not to reduce the quality of care and to explain that carrier/self-insured employer consultant physicians are available to discuss cases for which the attending physician feels the surgery must be performed on an inpatient basis.

b. Drawing on the strength of existing physician relations, the carrier/self-insured employer needs to stress continued cooperation between the carrier/self-insured employer physician consultant and the attending physician. In addition, the carrier/self-insured employer should develop ongoing physician communications, such as newsletters and attendance at community physician gatherings.

2. Implementation
a. Telephone Inquiry Service. Telephone numbers should be published in educational materials and standard form letters to physicians and claimants. This telephone service should provide for prompt response to inquiries regarding ambulatory surgery.

b. Appropriate Staff and Documentation. Registered nurses and physicians are the recommended staff for processing of ambulatory surgery requests and inquiries. Procedures must be available for timely review of cases which providers believe cannot be safely performed in an outpatient setting. Program procedures should be routine and documented.

3. Evaluation
a. Data Collection. Ambulatory surgery information should be linked to the claims system to properly process surgical claims. Ambulatory surgery elements should be retrievable on a claim-by-claim basis for compilation and classification of activity performance.

b. Plan Data Reporting. Carriers will be required to collect data for report preparation as outlined in the billing and maintenance section of the Office of Workers' Compensation Reimbursement Manual.

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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