Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1150 - MA PROGRAM PAYMENT POLICIES
GENERAL PROVISIONS
Section 1150.2 - Definitions

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

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

Adult-A person 21 years of age or older, unless otherwise specified in the MA Program Fee Schedule which is contained in the Provider's Handbook or in the specific provider regulations.

Anesthesia-The loss of feeling or sensation, especially the loss of tactile sensibility, or the loss of any of the senses.

Assistant surgeon-A licensed physician who assists another licensed physician with a surgical procedure.

Child-A person 20 years of age or younger, unless otherwise specified in the MA Program Fee Schedule which is contained in the Provider's Handbook or in the specific provider regulations.

Diagnostic services-Tests performed to make a diagnosis or to recognize or establish the nature of an illness. This service consists of medical diagnostic procedures-for example, electrocardiogram and electroencephalogram; surgical diagnostic procedures-for example, biopsies and amniocentesis; diagnostic radiology-for example, chest x-rays; nuclear medicine; and pathology-for example, examination of blood, urine, feces and tissue.

Elective admission-A preplanned admission to a hospital, short procedure unit or ambulatory surgical center. The term includes an admission in which scheduling options may be exercised by the attending practitioner, facility or recipient without unfavorably affecting the outcome of the treatment. The term does not include emergency or urgent admissions.

Emergency admission-An admission to a hospital for a condition in which immediate medical care is necessary to prevent death, serious impairment or significant deterioration of the health of the patient.

Experimental procedure-A procedure that deviates from customary standards of medical practice, is not routinely used in the medical or surgical treatment of a specific illness or condition or is not of proven medical value.

General anesthesia-The production of complete unconsciousness, muscular relaxation and absence of pain sensation used in performing surgical operations.

High risk delivery-A delivery in which the medical condition of the fetus or mother, or complications of pregnancy or delivery are life-threatening or significantly increase the likelihood of fetal or maternal morbidity or mortality.

Initial comprehensive visit-An inpatient hospital or nursing facility visit which includes the recording of the chief complaint, the description of the present illness, family history, past medical history, personal history, system review, a complete physical examination, treatment plan and the ordering of appropriate diagnostic tests.

Initial limited visit-An inpatient hospital or nursing facility visit which includes the recording of the chief complaint, the description of the present illness or current medical history, an appropriate physical examination related to the acute or active problem in a patient who has a previously documented evaluation that is current and available to the physician, the treatment plan and the ordering of appropriate diagnostic tests.

Local anesthesia-Anesthesia produced by local infiltration, digital block or topical application of an anesthetic agent.

Maternity admission-An admission of a pregnant woman that is intended to result in the delivery of at least one infant.

Medical care-The attention and treatment of a patient by a practitioner responsible for the medical management of the patient on an inpatient or outpatient basis.

Newborn-An infant born in the hospital or born on the way to a hospital who has not been discharged or transferred from that hospital since birth.

PSR-Place of Service Review-A process by which the Department reviews elective admissions to determine the compensability of the admission and the appropriate setting for the treatment for which the Department will make payment. PSRs take place prior to the admission of the patient.

Practitioner-A person currently licensed under the law of a state to practice medicine, osteopathy, dentistry, podiatry, optometry, chiropractic or midwifery.

Prolonged medical attention-Care of a patient whose condition requires the continuous presence of the physician by direct encounter with the patient for at least 1 hour; supportive documentation shall be recorded in the patient's medical record to indicate the medical necessity for the prolonged attention, the specific care provided and the actual time spent with the patient.

Radiation therapy-The treatment of a condition by use of x-ray, gamma ray, accelerated particle, mesons or neutrons.

Regional anesthesia-The production of insensibility of a part by interrupting the sensory nerve conductivity of a region of the body; it may be produced by one of the following:

Second opinion program-A process through which MA recipients receive the opinion of a second practitioner when there is a question as to the medical necessity or appropriateness of a procedure or if the procedure appears on the Department's list of procedures that automatically requires a second opinion as published as a statement of policy in the Pennsylvania Bulletin.

Urgent admission-An admission where medical care shall be administered promptly and cannot be delayed.

Visit-A face-to-face encounter between a patient and practitioner, except as otherwise stated in this part, for the purpose of furnishing medically necessary services.

The provisions of this §1150.2 amended under sections 443.1(1) and (4), 443.2(2)(ii) and 443.4 of the Public Welfare Code (62 P. S. §§ 443.1(1) and (4), 443.2(2)(ii) and 443.4).

This section cited in 55 Pa. Code § 1101.31 (relating to scope); and 55 Pa. Code § 1150.59 (relating to PSR program).