Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1150 - MA PROGRAM PAYMENT POLICIES
PAYMENT FOR SERVICES
Section 1150.56 - Medical services
Universal Citation: 55 PA Code ยง 1150.56
Current through Register Vol. 54, No. 12, March 23, 2024
(a) Inpatient medical care.
(1)
On any given day, a pracitioner may bill for only one of the following:
(i) An initial comprehensive visit.
(ii) An initial limited visit.
(iii) Prolonged medical attention.
(iv) A consultation.
(v) A surgical procedure.
(vi) An inpatient hospital visit.
(vii) An Early and Periodic Screening,
Diagnosis, and Treatment visit.
(viii) Stand-by services for high risk
deliveries or Cesarean sections.
(2) Medical visits are not paid to the same
practitioner who performs the surgery.
(3) Only one practitioner is eligible to
receive payment for medical care for the same patient on the same
day.
(4) A practitioner who
provides medical care may also bill for medical diagnostic procedures, surgical
diagnostic procedures, and radiation therapy for the same patient during the
same period of hospitalization.
(5)
During a period of hospitalization, payment may be made to one other
practitioner responsible for inpatient medical care, if provided, in addition
to the practitioner billing for surgical services.
(6) Payment for consultation is limited to
two consultations provided the same patient during the same period of
hospitalization.
(b) Nonhospital medical care.
(1) A practitioner may bill the Department
for medical care provided to an outpatient as an office visit, a skilled
nursing or intermediate care facility visit, or a home visit.
(2) In addition to a medical care visit, a
practitioner may bill for diagnostic radiology procedures, medical diagnostic
procedures, surgical diagnostic procedures, nuclear medicine procedures and
radiation therapy.
(3) On any given
day, a practitioner may bill for only one of the following per recipient:
(i) An initial visit in a skilled or
intermediate nursing facility.
(ii)
A medical visit.
(iii) An office
visit.
(iv) A
consultation.
(v) A surgical
procedure.
(vi) An EPSDT
visit.
(vii) A general medical
examination.
(4) For any
home visit, a practitioner may bill for no more than two patients.
(5) A practitioner may bill for services
performed in an emergency room only in accordance with the arrangement selected
by the hospital as specified in Chapter 1221 (relating to clinic and emergency
room services) and stated in a letter directed to and approved by the Office of
Medical Assistance, Bureau of Provider Relations. Arrangements may not be
changed without prior written agreement with the Bureau of Provider
Relations.
(6) A visit to a
practitioner's office or a hospital outpatient department solely for the
purpose of receiving a diagnostic service, administration of chemotherapy, or
for an injection of medication or vaccine does not qualify for payment as an
office visit, a hospital clinic emergency room visit or for a visit for support
services. In this kind of situation, payment will be made only for the
diagnostic service, the administration of chemotherapy, or for the injection of
medication or vaccine. Payment to a practitioner or hospital outpatient
department for a visit includes payment for administering any injections of
medication or vaccine.
Disclaimer: These regulations may not be the most recent version. Pennsylvania 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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