Haw. Code R. § 12-15-51 - Surgery

(a) When elective surgery is contemplated, the attending physician shall obtain permission from the employer at least seven calendar days prior to the date of the proposed surgery. Written notification shall include procedure code, medical documentation justifying the need for surgery, the estimated date of surgery, and the hospital where the surgery is to be performed. The notification shall permit the employer to determine whether the injured employee should be examined by a physician of the employer's choice as provided under section 386-79, HRS. Any physician who performs surgery in a manner which denies the rights of the employer as provided under section 386-79, HRS, shall forfeit the physician's right to fees. When the surgical procedure has a "BR" (by report) fee, the estimated fee shall be submitted with the request. The physician's request shall also specify the cost and need for a co-surgeon or assistant and other additional surgical procedures, if any.

(b) Whenever a request for elective surgery is received, the employer shall respond within seven calendar days after postmark of such request, giving authorization or stating in writing the reason for refusal, to the attending physician, the injured employee, and the director. The employer's denial of elective surgery shall be supported by health care recommendations and shall explicitly state that failure to request a review by the director of the employer's denial within fourteen calendar days after postmark of the employer's denial shall be construed as acceptance of the employer's denial. If a request for a surgical procedure has been denied, the attending physician may not resubmit the same request for the same surgical procedure for forty-five calendar days after postmark of the employer's denial. Failure by the employer to respond within seven calendar days shall constitute approval of the request.

(c) The attending physician or the injured employee may request in writing that the director review the employer's denial of the request for elective surgery. The request for review shall be filed with the director, copying the employer, within fourteen calendar days after postmark of the employer's denial. Failure to file a request for review of the employer's denial to the director within fourteen calendar days after postmark of the employer's denial shall be deemed acceptance of the employer's denial, and the attending physician may not resubmit the same request for the same surgical procedure for forty-five calendar days after postmark of the employer's denial. The director shall hold a hearing on the request for review, and issue a decision approving or denying the request for elective surgery based on the evidence presented (inclusive of records on file). The decision shall be final unless appealed pursuant to section 386-87, HRS. The appeal shall not stay the director's decision.

(d) Surgery which must be performed immediately or within fourteen calendar days because the condition is life-threatening or could cause serious harm is not considered elective surgery. The attending physician shall notify the director and the employer as soon as possible when emergency surgery is required.

(e) When a surgical fee is chargeable, no office or hospital visit charge shall be allowed for the day on which this surgical fee is earned, except if surgery is performed on the same day as the physician's first examination.

(f) Listed fees for all surgical procedures include the surgery and the follow-up care for the period indicated in days in the column headed "Follow-up Days" in the medical fee schedule. Necessary follow-up care beyond this listed period is to be added on a fee-for-service basis. Where the follow-up period is listed as zero, the listed fee is for the surgical procedure only, and all post-operative care is to be added on a fee-for-service basis.

(g) When additional surgical procedures are carried out within the listed period of follow-up care for a previous surgery, the follow-up periods shall continue concurrently to their normal terminations.

(h) Certain of the listed procedures in the medical fee schedule as provided in section 12-15-90 are commonly carried out as an integral part of a total service and, as such, do not warrant a separate charge. When such a procedure is carried out as a separate procedure, not immediately related to other services, the indicated fee is applicable.

(i) When significant time or complexity to patient care results from multiple or bilateral surgical procedures performed at the same operative session, the total fee shall be the fee for the major procedure plus fifty per cent of the fee of the lesser procedures unless otherwise specified in this chapter. When an incidental procedure (e.g., incidental appendectomy, lysis of adhesions, excision of previous scar) is performed through the same incision, the fee shall be that of the major procedure only.

(j) One attending physician shall be in charge of the care of the injured employee. However, if the nature of the injury requires the concurrent services of two or more specialists for treatment, then each physician shall be entitled to the listed fee for services rendered.

(k) Lacerations ordinarily require no aftercare except removal of sutures. The removal is considered a routine part of an office or hospital visit.

(l) For those fees not covered by Medicare, bills for services for injured employees who have had major surgery or treatment for major fractures and are later treated by another physician for follow-up care shall be limited to the fee schedule during the entire follow-up period as follows:

(1) The operating surgeon shall submit a fee, reducing it accordingly if aftercare is not rendered.

(2) The physician providing follow-up care shall submit the fee for the aftercare.

(3) It shall be the responsibility of the operating surgeon to advise the director or employer of the apportionment of the respective fees.

Notes

Haw. Code R. § 12-15-51

[Eff 1/1/96; am 1/1/97; am 12/17/01] (Auth: HRS §§ 386-26, 386-72) (Imp: HRS §§ 386-21, 386-26, 386-79)