Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1221 - CLINIC AND EMERGENCY ROOM SERVICES › PAYMENT FOR CLINIC AND EMERGENCY ROOM SERVICES › Section 1221.51 - General payment policy

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for clinic and emergency room services is subject
					 to the conditions and limitations in this chapter and Chapters 1101 and 1150
					 (relating to general provisions; and MA Program payment policies) and the MA
					 Program Fee Schedule. The following describes the payment policies applicable
					 to hospital outpatient clinics, medical school clinics, independent medical
					 clinics and hospital emergency rooms.
(1) Hospital outpatient clinics, medical
				  school clinics and independent medical clinics have the option of billing
				  either the fee for a specific compensable procedure performed in the clinic or,
				  but not in addition to, the flat visit fee except as noted in paragraph (7).
				  Compensable procedures are specified in the MA Program Fee Schedule. The visit
				  fee includes the professional, technical and support components of a clinic
				  visit. The visit fee includes medical services rendered by a physician or under
				  the supervision of a physician, drugs and biologicals administered or provided
				  during the clinic visit and services and supplies commonly rendered without
				  charge and incident to professional services. Visit fees are listed in the MA
				  Program Fee Schedule. Specific vaccines, as determined by the Department, and
				  listed in Chapter 1241, Appendix D (relating to EPSDT immunization
				  guidelines-statement of policy) are excluded from the established clinic fee
				  and may be billed separately by clinics approved by the Department.
(2) Reimbursement for abortions performed in
				  a clinic meeting the conditions set forth in §
										1221.57 (relating to payment
				  conditions for necessary abortions) is made on a component basis as listed in
				  the MA Program Fee Schedule.
(3)
				  The usual and customary charge to the general public for independent clinics
				  with fee schedules based on the ability of the patient to pay shall be the most
				  frequent charge to the self-paying public for the same service in the preceding
				  calendar month.
(4) Hospital
				  emergency rooms are paid a support component and a physicians component as set
				  forth in Chapter 1150. Diagnostic and radiology services are compensable in
				  addition to the physicians component as specified in paragraph (7).
(5) The hospital is considered the provider
				  regardless of whether the hospital clinics are operated directly by the
				  hospital or through contract between the hospital and other organizations or
				  individuals. The hospital is responsible for the delivery of service and for
				  billings.
(6) The medical school is
				  considered the provider for all services provided by medical school clinics and
				  is responsible for the delivery of the service and for billings.
(7) Diagnostic medical services, such as
				  electrocardiograms, electroencephalograms, electromyographies and diagnostic or
				  therapeutic radiology services provided during routine examination and
				  treatment services are compensable in addition to the flat visit fee or fee for
				  a specific compensable procedure. Endoscopic procedures, such as rhinoscopy,
				  otoscopy or indirect laryngoscopy performed in the course of the visit are not
				  compensable in addition to the flat visit fee.
(8) When two or more surgical operations are
				  performed at the same time, or during the same visit, the procedure carrying
				  the highest fee will be paid in full, plus 25% of the fee for the next highest
				  procedure, with no allowance for additional procedures. The total fee allowance
				  may not exceed $200.
This section cited in 55 Pa. Code §
												1147.53 (relating to limitations
						on payment); 55 Pa. Code §
												1221.58 (relating to limitations
						on payment); and 55 Pa. Code §
												1221.59 (relating to
						noncompensable services and items).