Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1150 - MA PROGRAM PAYMENT POLICIES › GENERAL PROVISIONS › Section 1150.2 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Adult
-A person 21 years of age or older,
					 unless otherwise specified in the MA Program Fee Schedule which is contained in
					 the Provider's Handbook or in the specific provider regulations.
Anesthesia
-The loss of feeling or
					 sensation, especially the loss of tactile sensibility, or the loss of any of
					 the senses.
Assistant surgeon
-A licensed physician who
					 assists another licensed physician with a surgical procedure.
Child
-A person 20 years of age or younger,
					 unless otherwise specified in the MA Program Fee Schedule which is contained in
					 the Provider's Handbook or in the specific provider regulations.
Diagnostic services
-Tests performed to
					 make a diagnosis or to recognize or establish the nature of an illness. This
					 service consists of medical diagnostic procedures-for example,
					 electrocardiogram and electroencephalogram; surgical diagnostic procedures-for
					 example, biopsies and amniocentesis; diagnostic radiology-for example, chest
					 x-rays; nuclear medicine; and pathology-for example, examination of blood,
					 urine, feces and tissue.
Elective admission
-A preplanned admission
					 to a hospital, short procedure unit or ambulatory surgical center. The term
					 includes an admission in which scheduling options may be exercised by the
					 attending practitioner, facility or recipient without unfavorably affecting the
					 outcome of the treatment. The term does not include emergency or urgent
					 admissions.
Emergency admission
-An admission to a
					 hospital for a condition in which immediate medical care is necessary to
					 prevent death, serious impairment or significant deterioration of the health of
					 the patient.
Experimental procedure
-A procedure that
					 deviates from customary standards of medical practice, is not routinely used in
					 the medical or surgical treatment of a specific illness or condition or is not
					 of proven medical value.
General anesthesia
-The production of
					 complete unconsciousness, muscular relaxation and absence of pain sensation
					 used in performing surgical operations.
High risk delivery
-A delivery in which the
					 medical condition of the fetus or mother, or complications of pregnancy or
					 delivery are life-threatening or significantly increase the likelihood of fetal
					 or maternal morbidity or mortality.
Initial comprehensive visit
-An inpatient
					 hospital or nursing facility visit which includes the recording of the chief
					 complaint, the description of the present illness, family history, past medical
					 history, personal history, system review, a complete physical examination,
					 treatment plan and the ordering of appropriate diagnostic tests.
Initial limited visit
-An inpatient
					 hospital or nursing facility visit which includes the recording of the chief
					 complaint, the description of the present illness or current medical history,
					 an appropriate physical examination related to the acute or active problem in a
					 patient who has a previously documented evaluation that is current and
					 available to the physician, the treatment plan and the ordering of appropriate
					 diagnostic tests.
Local anesthesia
-Anesthesia produced by
					 local infiltration, digital block or topical application of an anesthetic
					 agent.
Maternity admission
-An admission of a
					 pregnant woman that is intended to result in the delivery of at least one
					 infant.
Medical care
-The attention and treatment
					 of a patient by a practitioner responsible for the medical management of the
					 patient on an inpatient or outpatient basis.
Newborn
-An infant born in the hospital or
					 born on the way to a hospital who has not been discharged or transferred from
					 that hospital since birth.
PSR-Place of Service Review
-A process by
					 which the Department reviews elective admissions to determine the
					 compensability of the admission and the appropriate setting for the treatment
					 for which the Department will make payment. PSRs take place prior to the
					 admission of the patient.
Practitioner
-A person currently licensed
					 under the law of a state to practice medicine, osteopathy, dentistry, podiatry,
					 optometry, chiropractic or midwifery.
Prolonged medical attention
-Care of a
					 patient whose condition requires the continuous presence of the physician by
					 direct encounter with the patient for at least 1 hour; supportive documentation
					 shall be recorded in the patient's medical record to indicate the medical
					 necessity for the prolonged attention, the specific care provided and the
					 actual time spent with the patient.
Radiation therapy
-The treatment of a
					 condition by use of x-ray, gamma ray, accelerated particle, mesons or
					 neutrons.
Regional anesthesia
-The production of
					 insensibility of a part by interrupting the sensory nerve conductivity of a
					 region of the body; it may be produced by one of the following:
(i) A field block, the creation of walls of
				  anesthesia encircling the operative field by means of injections of a local
				  anesthetic.
(ii) A nerve block, the
				  making of extraneural or paraneural injections in proximity to the nerves where
				  conductivity is to be cut off.
Second opinion program
-A process through
					 which MA recipients receive the opinion of a second practitioner when there is
					 a question as to the medical necessity or appropriateness of a procedure or if
					 the procedure appears on the Department's list of procedures that automatically
					 requires a second opinion as published as a statement of policy in the
Pennsylvania Bulletin.
Urgent admission
-An admission where
					 medical care shall be administered promptly and cannot be delayed.
Visit
-A face-to-face encounter between a
					 patient and practitioner, except as otherwise stated in this part, for the
					 purpose of furnishing medically necessary services.
The provisions of this §
												1150.2 amended under sections
						443.1(1) and (4),
						443.2(2)(ii) and 443.4 of the Public Welfare Code (62 P. S. §§
													443.1(1) and (4),
						443.2(2)(ii) and 443.4).
This section cited in 55 Pa. Code §
												1101.31 (relating to scope); and
						55 Pa. Code §
												1150.59 (relating to PSR
						program).