55 Pa. Code § 1126.53 - Limitations on covered procedures
(a)
Payment will be made for same day surgical procedures listed by the department
as compensable when provided under §
1126.1 (relating to
policy).
(b) Payment for procedures
that are appropriate for same day surgery but are not yet included in the
established list of covered ASC/SPU services is limited to:
(1) The specific fee for each procedure
developed by the Department when enough data is obtained to establish a
fee.
(2) Prior to establishment of
a fee, the Statewide average cost of same day surgery developed by the
Department.
(c) Payment
will be made for services performed in an approved ASC/SPU only if the service
could not be appropriately and safely performed in the practitioner's office,
the clinic or the emergency room of a hospital, because the medical needs of
the patient require less than 24-hour care, and the use of inpatient hospital
resources, especially an operating room, and in some cases administration of
general anesthesia.
Notes
This section cited in 55 Pa. Code § 1126.41 (relating to participation requirements).
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