Current through Vol. 42, No. 1, September 16, 2024
(a)
Use of
medical modifiers. The physicians' Current Procedural Terminology (CPT)
and the second level Healthcare Common Procedure Coding System (HCPCS) provide
for 2-digit medical modifiers to further describe medical services. Modifiers
are used when appropriate.
(b)
Covered office services.
(1)
Payment is made for four(4) office visits (or home) per month per member, for
adults [over age twenty-one (21)] , regardless of the number of physicians
involved. Additional visits per month are allowed for services related to
emergency medical conditions.
(2)
Visits for the purpose of family planning are excluded from the four(4) per
month limitation.
(3) Payment is
allowed for the insertion and/or implantation of contraceptive devices in
addition to the office visit.
(4)
Separate payment will be made for the following supplies when furnished during
a physician's office visit.
(A) Casting
materials;
(B) Dressing for burns;
(C) Contraceptive devices; and
(D) IV fluids.
(5) Medically necessary office lab
and X-rays are covered.
(6) Hearing
exams by physician for members between the ages of twenty one (21) and sixty
five (65) are covered only as a diagnostic exam to determine type, nature and
extent of hearing loss.
(7) Hearing
aid evaluations are covered for members under twenty one (21) years of age.
(8) IPPB (Intermittent Positive
Pressure Breathing) is covered when performed in physician's office.
(9) Payment is made for an office visit in
addition to allergy testing.
(10)
Separate payment is made for antigen.
(11) Eye exams are covered for members
between ages twenty one (21) and sixty five (65) for medical diagnosis only.
(12) If a physician personally
sees a member on the same day as a dialysis treatment, payment can be made for
a separately identifiable service unrelated to the dialysis.
(13) Separate payment is made for the
following specimen collections:
(A)
Catheterization for collection of specimen; and
(B) Routine venipuncture .
(14) The Professional Component
for electrocardiograms, electroencephalograms, electromyograms, and similar
procedures are covered on an inpatient basis as long as the interpretation is
not performed by the attending physician.
(15) Cast removal is covered only when the
cast is removed by a physician other than the one who applied the cast.
(16) Payment may be made for
medication-assisted treatment (MAT) medications prescribed and/or administered
by a physician.
(c)
Non-covered office services.
(1)
Payment is not made separately for an office visit and rectal exam, pelvic exam
or breast exam. Office visits including one of these types of exams should be
coded with the appropriate office visit code.
(2) Payment cannot be made for prescriptions
or medication dispensed by a physician in his office.
(3) Payment will not be made for completion
of forms, abstracts, narrative reports or other reports, separate charge for
use of office or telephone calls.
(4) Additional payment will not be made for
mileage.
(5) Payment is not made
for an office visit where the member did not keep appointment.
(6) Refractive services are not covered for
persons between the ages of twenty-one (21) and sixty-five (65) .
(7) Removal of stitches is considered part of
post-operative care.
(8) Payment is
not made for a consultation in the office when the physician also bills for
surgery.
(9) Separate payment is
not made for oxygen administered during an office visit.
(d)
Covered inpatient medical
services.
(1) Payment is allowed for
inpatient hospital visits for all SoonerCare covered admissions. Psychiatric
admissions must be prior authorized.
(2) Payment is allowed for the services of
two physicians when supplemental skills are required and different specialties
are involved.
(3) Certain medical
procedures are allowed in addition to office visits.
(4) Payment for critical care is
all-inclusive and includes payment for all services that day. Payment for
critical care, first hour is limited to one unit per day.
(e)
Non-covered inpatient medical
services.
(1) For inpatient services,
all visits to a member on a single day are considered one service except where
specified. Payment is made for only one(1) visit per day.
(2) A hospital admittance or visit and
surgery on the same day would not be covered if post-operative days are
included in the surgical procedure. If there are no post-operative days, a
physician can be paid for visits.
(3) Drugs administered to inpatients are
included in the hospital payment.
(4) Payment will not be made to a physician
for an admission or new patient work-up when the member receives surgery in
out-patient surgery or ambulatory surgery center.
(5) Payment is not made to the attending
physician for interpretation of tests on his own patient.
(f)
Other medical services.
(1) Payment will be made to physicians
providing Emergency Department services.
(2) Payment is made for two(2) nursing
facility visits per month. The appropriate CPT code is used.
(3) When payment is made for evaluation of
arrhythmias or evaluation of sinus node , the stress study of the arrhythmia
includes inducing the arrhythmia and evaluating the effects of drugs, exercise,
etc. upon the arrhythmia.
(4) When
the physician bills twice for the same procedure on the same day, it must be
supported by a written report.
Added at 12 Ok Reg
751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
7-27-95; Amended at 13 Ok Reg 3607, eff 6-18-96 (emergency); Amended at 14 Ok
Reg 1780, eff 5-27-97; Amended at 16 Ok Reg 155, eff 10-14-98 (emergency);
Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 3413, eff 7-1-99
(emergency); Amended at 17 Ok Reg 2373, eff 6-26-00; Amended at 17 Ok Reg 3469,
eff 8-1-00 (emergency); Amended at 18 Ok Reg 761, eff 1-23-01 (emergency);
Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2134, eff 6-27-02;
Amended at 21 Ok Reg 501, eff 1-1-04 (emergency); Amended at 21 Ok Reg 2176,
eff 6-25-04; Amended at 23 Ok Reg 239, eff 10-3-05 through 7-14-06
(emergency)1; Amended at 25 Ok Reg 121, eff 8-1-07
(emergency); Amended at 25 Ok Reg 1192, eff 5-25-08; Amended at 26 Ok Reg 2088,
eff 6-25-09; Amended at 27 Ok Reg 294, eff 11-3-09 (emergency); Amended at 27
Ok Reg 1439, eff 6-11-10; Amended at 28 Ok Reg 1412, eff
6-25-11
1This emergency action expired
without being superseded by a permanent action. Upon expiration of an emergency
amendatory action, the last effective permanent text is reinstated. Therefore,
on 7-15-06 (after the 7-14-06 expiration of the emergency action), the text of
317:30-5-9 reverted back to the permanent text that became effective 6-25-04,
as was last published in the 2005 OAC Supplement, and remained as such until
amended again by emergency action on 8-1-07.
