Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 109. Surgical procedures

7 AAC 43.109. Surgical procedures

The division will reimburse an enrolled in-state physician for surgical procedures in accordance with 7 AAC 43.040, subject to the following exceptions:

(1) the highest valued procedure of multiple surgeries performed on the same patient during the same operative session or on the same day will be reimbursed at 100 percent of the rate identified in the fee schedule established under 7 AAC 43.108 and each additional surgery will be reimbursed at 50 percent of the rate identified in that fee schedule;

(2) bilateral surgeries will be reimbursed at 150 percent of the rate identified in the fee schedule established under 7 AAC 43.108;

(3) co-surgeons will be reimbursed for the same surgical procedure, if medically necessary, by increasing the payment under the fee schedule established under 7 AAC 43.108 by 25 percent and splitting the payment equally between the surgeons;

(4) intraoperative procedures billed using modifier -54 will be reimbursed at the lesser of billed charges or 80 percent of the rate identified in the fee schedule established under 7 AAC 43.108;

(5) preoperative services billed using modifier -56 or postoperative services billed using modifier -55 that are performed by a physician other than the surgeon will be paid at the lesser of billed charges or 10 percent of the rate identified in the fee schedule established under 7 AAC 43.108; and

(6) supplies associated with surgical procedures performed in a physician's office will be reimbursed in accordance with Table I-7 of the physician services section of the Alaska Medicaid Provider Billing Manual, dated September 1996, at the lesser of billed charges or the conversion factor identified in 7 AAC 43.108(a) (3). The September 1996 revision of Table I-7 of the physician services section of the Alaska Medicaid Provider Billing Manual is adopted by reference.

History: Eff. 2/1/97, Register 141

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

Editor's note: The September 1996 revision of Table I-7 of the physician services section of the Alaska Medicaid Provider Billing Manual may be obtained by contacting the Department of Health and Social Services, Division of Medical Assistance, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska 99503-7167.