Or. Admin. Code § 410-130-0240 - Medical Services
(1)
Coverage of medical and surgical services is subject to the Health Evidence
Review Commission's (HERC) Prioritized List of Health Services (Prioritized
List). Medical and surgical services requiring prior authorization (PA) are
listed in Oregon administrative rule (OAR or rule)
410-130-0200, PA Table
130-0200-1, and medical and surgical services that are Not Covered/Bundled
services are listed in OAR
410-130-0220, Table 130-0220-1.
(2) Coverage for acupuncture
services by an enrolled acupuncture provider are subject to the HERC
Prioritized List and the client's benefit plan.
(3) Coverage for medically appropriate
chiropractic services provided by an enrolled chiropractor is subject to the
HERC Prioritized List and benefit plan for:
(a) Diagnostic visits including evaluation
and management services;
(b)
Chiropractic care including manipulative treatment;
(c) Laboratory and radiology services.
(4) Maternity care and
delivery:
(a) The Division may consider
payment for delivery within a hospital, clinic, birthing center, or home
setting;
(b) For out-of-hospital
births, the Division may only consider payment for labor and delivery care of
women experiencing low risk pregnancy. The Division will determine whether a
pregnancy can be considered low risk and an out-of-hospital birth is eligible
for payment;
(c) The Division
adopts Table I from OAR
333-076-0650 to outline the
absolute risk factors that, if present, would preclude payment for initiation
or continuation of any out-of-hospital labor and delivery care. For a planned
out-of-hospital birth, the Division requires that a contingency for an
in-hospital birth be included in the medical record. The division considers all
conditions listed in Table I of OAR
333-076-0650 to necessitate an
in-hospital birth if present or anticipated to be present at the onset of
labor. The Division may deny payment for labor and delivery services in an
out-of-hospital setting if it determines that an in-hospital birth was
necessary and appropriate steps to facilitate an in-hospital birth were not
pursued. When an in-hospital birth becomes necessary for a client that was
seeking a planned out-of-hospital birth and care is transferred from one
provider to another, the Division will consider payment for both providers for
the portion of care provided. Bill using appropriate CPT and HCPCS codes.
(d) When a provider is practicing
within the authorization of his or her license, the division may consider
payment for administration of drugs and devices that are used in pregnancy,
birth, postpartum care, newborn care, or resuscitation and that are deemed
integral to providing safe care.
(e) For out-of-hospital births, drugs
authorized in subsection (d) or this section are limited:
(A) For out-of-hospital births, the Division
will make no payment for general, spinal, caudal, or epidural anesthesia
administered for care associated with labor and delivery;
(B) For out-of-hospital births, the Division
will make no payment for inducing, stimulating, or using chemical agents to
augment labor during the first or second stages of labor;
(C) For out-of-hospital births, the Division
will consider payment for chemical agents administered to inhibit labor only as
a temporary measure until referral or transfer of the client to a higher level
of care is complete.
(f)
Within the home setting, the Division may consider payment for appropriate
supplies in addition to delivery payment. The additional payment for supplies
includes all supplies, equipment, staff assistance, and newborn screening
cards;
(g) During labor in an
out-of-hospital setting, should any of the risk factors outlined in Table II of
OAR 333-076-0650 develop, the
Division requires that the client will be transferred to a hospital, and the
Division may deny payment for labor and delivery services if it determines that
appropriate steps to facilitate the transfer were not pursued. Appropriate
transfer of care must be in accordance with the practitioner's licensure
requirements. When labor management does not result in a delivery, and the
client is appropriately transferred to a higher level of care, the provider
shall code for labor management only. Bill code 59899 and attach appropriate
clinical documentation of services performed with respect to labor management;
(h) For births in an
out-of-hospital setting, should any of the risk factors outlined in Table III
of OAR 333-076-0650 develop during the
postpartum period in the mother or infant, the Division requires that the
client will be transferred to a hospital, and the Division may deny payment for
labor and delivery services if it determines that appropriate steps to
facilitate the transfer were not pursued. Appropriate transfer of care must be
in accordance with the practitioner's licensure requirements. The Division will
consider payment for both providers for the portion of care provided when
appropriate;
(i) For multiple
vaginal births, use the appropriate CPT code for the first delivery. Use the
delivery-only code for the subsequent deliveries. The Division will reimburse
the first delivery at 100 percent and the subsequent deliveries at 50 percent
of the delivery-only code's maximum allowance. For multiple babies delivered
via cesarean section, the Division pays for the cesarean section only once.
(5) Neonatal Intensive
Care Unit (NICU) procedures:
(a) Are
reimbursed only to neonatologists and pediatric intensivists for services
provided to infants when admitted to a Neonatal or Pediatric Intensive Care
Unit (NICU/PICU). All other pediatricians must use other CPT codes when billing
for services provided to neonates and infants;
(b) Neonatal intensive care codes are not
payable for infants on Extracorporeal Membrane Oxygenation (ECMO). Use
appropriate CPT ECMO codes.
(6) Neurology or Neuromuscular payment for
polysomnograms and multiple sleep latency tests (MSLT) are each limited to two
in a 12-month period.
(7) Oral
health services provided by medical practitioners may include an oral
assessment and application of topical fluoride varnish during a medical visit
for children. Refer to OAR
410-123-1260 Dental Services
program rule.
Notes
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025 & 414.065
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