Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1163 - INPATIENT HOSPITAL SERVICES
Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM
PAYMENT FOR HOSPITAL SERVICES
Section 1163.59 - Noncompensable services, items and outlier days
Universal Citation: 55 PA Code ยง 1163.59
Current through Register Vol. 54, No. 44, November 2, 2024
(a) The Department does not pay hospitals for an inpatient hospital stay if the admission is directly or indirectly related to the hospital's provision of:
(1)
Transsexual surgical procedures for gender change or reassignment-for example,
penile construction, revision of labia, vaginoplasty, vaginal dilation, vaginal
reconstruction, penectomy, orchiectomy, mammoplasty, mastectomy, hysterectomy
and release of vaginal adhesions.
(2) Medical or dental services or surgical
procedures performed on an inpatient basis which could have been performed in
an outpatient department, or practitioner's office-for example, unilateral or
bilateral myringotomy, vasectomy, blood transfusions, chronic maintenance
hemodialysis, treatment for chronic pain and dental procedures which may be
provided in an outpatient setting without undue risk to the patient.
(3) Inpatient hospital services provided in
conjunction with physicians' services which are identified as outpatient
procedures in Chapter 1150 (relating to the MA Program payment policies),
unless performing the procedure on an outpatient basis could result in undue
risk to the life or health of the patient and detailed documentation of the
conditions of risk to the life or health of the patient is included in the
patient's medical record.
(4)
Acupuncture, unnecessary surgery, insertion of penile prosthesis, gastroplasty
for morbid obesity, gastric stapling or ileojejunal shunt, except when all
other types of treatment of morbid obesity have failed and other procedures
which may be experimental are not in accordance with customary standards of
medical practice or are not commonly used.
(5) Plastic or cosmetic surgery for
beautification purposes-for example, otoplasty for protruding ears or lop ears,
rhinoplasty-except for internal nasal deformity-nasal reconstruction, excision
of keloids, reduction mammoplasty, augmentation mammoplasty, silicone or
silastic implants, facioplasty, osteoplasty-prognathism and
micrognathism-dermabrasion, skin grafts and lipectomy. For accidental injury,
plastic surgery is compensable if performed for the purpose of improving the
functioning of a deformed body member.
(6) Inpatient dental cases involving oral
rehabilitation or restorative services, except for procedures performed for
treatment of a secondary diagnosis, unless:
(i) The nature of the surgery or the
condition of the patient precludes performing the procedure in the dentist's
office or other outpatient setting.
(ii) A physician or dentist has documented in
the patient's medical record the medical justification for performing the
procedure in a short procedure unit or inpatient setting.
(7) Diagnostic tests and procedures that can
be performed on an outpatient basis and diagnostic tests and procedures not
related to the diagnoses that require that particular inpatient stay.
(8) Sterilizations performed on individuals
20 years of age or younger.
(9)
Sterilizations performed on individuals 21 years of age or older who have not
signed the consent form for sterilization at least 30 days but not more than
180 days prior to the sterilization.
(10) Hysterectomies performed solely for the
purpose of sterilization.
(11)
Abortion procedures performed on individuals if a "Physician Certification for
an Abortion" form has not been completed.
(12) Services and items for which full
payment is available through Medicare, other financial resources or other
health insurance programs.
(13)
Services and items not ordinarily provided to the general public.
(14) Methadone maintenance.
(15) Diagnostic or therapeutic procedures
solely for experimental, research or educational purposes.
(16) Unnecessary admissions and conditions
which do not require hospital-type care, such as rest cures and room and board
for relatives during a patient's hospitalization.
(b) The Department does not pay for an inpatient hospital stay if the admission is not certified under the Department's DRG review process.
(c) For purposes of determining a day outlier under § 1163.56 (relating to outliers) the following days are excluded:
(1) Days of
absence from the hospital.
(2)
Inpatient days for patients who no longer require acute short term inpatient
hospital care-inappropriate hospital services. For patients who require skilled
nursing or intermediate care, payment is made to the hospital for this care
under Chapter 1181 (relating to nursing facility care) only if the patient is
in a certified and approved hospital-based skilled nursing or intermediate care
unit.
(3) Days of inpatient care
due to unnecessary delays in applying for a court ordered commitment, grace
periods, administrative days and custodial care related or unrelated to court
commitments or to protective services. For purposes of this chapter, custodial
care is defined as maintenance, rather than curative care, on an indefinite
basis, while grace periods and administrative days relate to days of care while
awaiting placement elsewhere.
(4)
Days spent as an inpatient at the transferring hospital on or after the
effective date of a court commitment to another facility.
(5) Inpatient days caused by the hospital's
failure to promptly request or perform necessary diagnostic studies,
medical-surgical procedures or consultations.
(6) Inpatient days when the patient is
admitted on a Friday or Saturday and no medical or surgical procedure is
performed on the day of or the day following admission, unless the admission is
an emergency as documented in the patient's medical record by the attending
physician.
(7) Inpatient days
resulting from the provision of a noncompensable service or item specified in
subsection (a).
(8) Inpatient days
resulting from a patient's refusal to leave the hospital after being discharged
by the attending physician.
(9) The
day of discharge from inpatient hospital care.
(d) The Department will not make payment for drug or alcohol detoxification services in an inpatient hospital unless one of the following circumstances exist:
(1)
Complications exist, or there is a reasonable expectation of complications,
that require inpatient hospital medical treatment, including:
(i) The presence or reasonable expectation,
based on history or other demonstrable findings, of potentially dangerous
withdrawal symptoms which could endanger the health or safety of the
individual.
(ii) The presence or
reasonable expectation, based on history or other demonstrable findings, of
major medical complications.
(iii)
The presence of a significant psychiatric problem on admission.
(iv) The presence of a clinical state
requiring close medical observation.
(2) A nonhospital, medically appropriate bed
is not available within a 50-mile radius of the inpatient hospital to which the
patient presents for treatment and the inpatient hospital includes
documentation of the nonavailability of the nonhospital detoxification bed in
the medical record. A nonhospital detoxification bed will be considered to be
not available if the medically appropriate nonhospital facility has no beds
available or refuses to accept the patient.
The provisions of this §1163.59 amended under sections 201(2) and 443.1(1) and (4) of the Public Welfare Code (62 P. S. §§ 201(2) and 443.1(1) and (4)).
This section cited in 55 Pa. Code § 1150.59 (relating to PSR Program); and 55 Pa. Code § 1163.78b (relating to review requirements for cost outliers).
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