Current through Register Vol. 46, No. 39, September 25, 2024
(a)
Basis for reimbursement. Reimbursement for physicians' services for which a
maximum reimbursable allowance has been established in this Part shall be based
upon payments actually made. However, reimbursement shall not be available for
amounts paid in excess of the maximum reimbursable allowance prescribed nor for
services not included in Part 505 of this Subchapter.
(1) If a physicians' service or procedure for
which no maximum reimbursable allowance has been established in this Part is
necessarily rendered, reimbursement shall be based upon the expenditures
actually made therefor, in accordance with applicable regulations of the
department.
(2) If, in accordance
with the accepted practice, a physician's service or a procedure hereinafter
listed in this Part is commonly carried out as an integral part of the total
service, only the value of the principal service or procedure shall be the
basis for reimbursement. When such a procedure is carried out as a separate
entity not immediately related to other services, reimbursement shall be based
upon the fee for the particular service or procedure.
(i) When a special procedure is performed
during a medical emergency when the physician is rendering intensive care,
items 9072 and 9073, for which there would be a separate allowance,
reimbursement shall be available for the higher of the two allowances, i.e.,
the allowance for service or allowance for time.
(3) If immunization is administered at the
time of an office visit, reimbursement will be based upon the immunization fee
in addition to the fee appropriate for the level of services provided during an
office visit.
(4) Charges for
special diagnostic procedures which are not considered to be a routine part of
a physician's or consultant's examination ( e.g., complete blood count,
diagnostic X-ray, lumbar puncture) are reimbursable in addition to the
physician's usual office or home visit fee.
(b) Intensive or unusual services.
(1) For intensive or unusual medical
treatment rendered to a patient who has an illness of such serious, critical or
unusual nature as to require time and study far beyond normal limits, a fee in
excess of that listed in the fee schedule may be approved by the appropriate
authority. Decision shall be based on the facts of the case supplied by the
attending physician.
(2) When a
special procedure is performed during a medical emergency for which there would
be a separate fee, the physician shall receive the higher of the two fees (fee
for special service or fee for time).
(c) Services by more than one physician. When
warranted by the necessity of supplemental skills, reimbursement shall be
available for expenditures for services rendered to a patient by two or more
physicians.
(d) Multiple visits. If
an individual patient is necessarily seen on more than one occasion during a
single day, expenditures for each such visit shall be subject to
reimbursement.
(e) Drugs and
supplies. Expenditures made by a social services district for necessary drugs,
materials and supplies provided by a physician, where separate payment therefor
is made in accordance with the local medical plan, shall be subject to
reimbursement in accordance with applicable regulations of the
department.
(f) Consultation fees.
(1) Reimbursement for consultation fee
expenditures shall be available only when an examination is made by an
accredited specialist, within the scope of his specialty, upon request of the
responsible physician who is treating the medical problem for which
consultation is required. The responsible physician shall certify that he
requested such consultation and that it was incident to and necessary for his
further treatment of the patient.
(2) When the consultant physician assumes the
continuing care of the patient, any subsequent services rendered by him shall
not be considered as consultation, and the established visit fees shall
apply.
(g) Specialists'
fees. Reimbursement for a specialist's fee shall be available only where the
services rendered are within the field of his specialty. Services performed by
a specialist outside his field of specialization shall be charged in accordance
with the general practitioner's fee schedule.
(h) Complete physical examination.
Reimbursement for expenditures for a complete physical examination shall be
available only when such examination has prior approval by the appropriate
authority except when such examination is required in an emergency.
(i) Telephone calls. The services rendered by
a physician directly to a patient over the telephone are not reimbursable. Long
distance calls by a physician to another physician who has previously attended
the patient or to a hospital or other medical facility to obtain additional
medical information are reimbursable.
