Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1126 - AMBULATORY SURGICAL CENTER SERVICES AND HOSPITAL SHORT PROCEDURE UNIT SERVICES
PAYMENT FOR SAME DAY SURGICAL SERVICES
Section 1126.53 - Limitations on covered procedures

Universal Citation: 55 PA Code ยง 1126.53

Current through Register Vol. 54, No. 44, November 2, 2024

(a) Payment will be made for same day surgical procedures listed by the department as compensable when provided under § 1126.1 (relating to policy).

(b) Payment for procedures that are appropriate for same day surgery but are not yet included in the established list of covered ASC/SPU services is limited to:

(1) The specific fee for each procedure developed by the Department when enough data is obtained to establish a fee.

(2) Prior to establishment of a fee, the Statewide average cost of same day surgery developed by the Department.

(c) Payment will be made for services performed in an approved ASC/SPU 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.

This section cited in 55 Pa. Code § 1126.41 (relating to participation requirements).

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