Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 1 - PHYSICIANS › Section 317:30-5-8 - Surgery

Current through Vol. 41, No. 20, July 1, 2024
(a) The OHCA uses
				  certain nationally recognized coding and editing guidelines for determination
				  of reimbursement logic related to situations including, but not limited to,
				  multiple, bilateral, assistant surgery, incidental, and mutually exclusive
				  procedure codes. When a procedure is performed for which specific procedure
				  codes exist, the specific procedure code must be used. A claim submitted with
				  an "unlisted" procedure code is subject to medical review and requires the
				  submission of all pertinent medical records for determination of
				  payment.
(b) The Physicians'
				  Current Procedural Terminology (CPT) provides for 2-digit modifiers to further
				  describe surgical services. These modifiers must be used on OHCA claims when
				  applicable.
(c) Reduction
				  mammoplasty is covered only when the procedure has been determined medically
				  necessary; prior authorization is required.
(d) Intradermal introduction of pigments or
				  tattooing is compensable when related to breast reconstruction; prior
				  authorization is required.
Added at 12 Ok Reg
					 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff
					 7-27-95; Amended at 13 Ok Reg 3185, eff 6-18-96 (emergency); Amended at 14 Ok
					 Reg 1780, eff 5-27-97; Amended at 14 Ok Reg 3103, eff 6-17-97 (emergency);
					 Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 18 Ok Reg 2952, eff 5-17-01
					 (emergency); Amended at 19 Ok Reg 1067, eff 5-13-02; Amended at 21 Ok Reg 2201,
					 eff 6-25-04; Amended at 24 Ok Reg 143, eff 10-8-06 (emergency); Amended at 24
					 Ok Reg 671, eff 2-1-07 (emergency)1; Amended at 24
					 Ok Reg 2824, eff 5-1-07 through 7-14-08
					 (emergency)2; Amended at 25 Ok Reg 2655, eff
					 7-25-08
1Pursuant to 75 O.S., Section
						253, the 2-1-07 emergency amendments to this section 317:30-5-8 were scheduled
						to expire on 7-15-07, if not already superseded by a permanent action or by
						another emergency action(s) that retained the same 7-15-07 expiration date. If
						the emergency action expired, the text of the section would then revert back to
						the permanent text that became effective prior to the 2-1-07 emergency action .
						As of 7-15-07, the agency had not supserseded the 2-1-07 emergency amendments
						with a permanent action or with another emergency action that retained the
						7-15-07 expiration date. However, on 5-1-07, the agency did issue another
						emergency action amending the section, but citing a later expiration date of
						7-15-08.
2This emergency action expired
						before being superseded by a permanent action. Upon expiration of an emergency
						amendatory action, the last effective permanent text is reinstated. Therefore,
						on 7-15-08 (after the 7-14-08 expiration of the emergency action), the text of
						317:30-5-8 reverted back to the permanent text that became effective 6-25-04,
						as was last published in the 2006 Edition of the OAC, and remained as such
						until amended again by permanent action on
						7-25-08.