La. Admin. Code tit. 48 § I-11525

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-11525 - Ambulatory Surgery

A. Description

1. Ambulatory surgery is elective minor surgery for pre-examined and diagnosed low-risk patients. Ambulatory surgery is limited to excisional, incisional, or repair procedures which require local, regional, or general anesthesia followed by at least an hour of professional post operative observation, but do not require overnight inpatient care. It does not include procedures which can be safely and efficiently performed in a doctor's office or a clinic, or cases normally handled in the emergency room. It has been estimated that over 40 percent of all hospital operations could be performed on a same-day basis, saving the national health care delivery system between ten and fifteen billion dollars annually.

2. Some of the advantages of ambulatory surgery are reduced costs, more effective use of physicians' time, greater bed availability, and earlier return to work. Additionally, studies have shown that ambulatory surgery creates less psychological stress and less physical isolation for patients than inpatient hospital surgery. Because of the short stay, there is less exposure of the patient to hospital-acquired infections, and less need for pre-operative and post-operative medication.

3. For Section 1122 purposes, an ambulatory surgery facility is a facility, not a part of a hospital, which provides surgical treatment to patients not requiring hospitalization. The term does not include offices of private physicians or dentists, whether for individual or group practice. Ambulatory surgery facilities can be either hospital-based or free-standing. Hospital-based ambulatory surgery facilities are distinguished from same day surgery services provided in hospitals in that hospital-based ambulatory surgery facilities are used solely for ambulatory surgery and are licensed as hospital-based ambulatory surgery facilities.

B. Cost/Payment

1. Medicare and Medicaid provide payment for hospital-based ambulatory surgery, and for ambulatory surgery performed in free-standing facilities, if the services are medically necessary and the facility meets state and federal regulations. Blue Cross and most other hospitalization insurance programs reimburse for ambulatory surgery based on what is covered in the individual subscriber's contract. Generally, the procedure must be a medically necessary service which cannot be performed in a physician's office. Depending on the terms of coverage, hospitalization insurance programs can serve to promote or reduce the incidence of ambulatory surgery. Most health insurance programs, both public and private, recognize the potential savings offered by ambulatory surgery, and some policies offer financial incentives which promote ambulatory surgery. For example, Medicare does not pay for certain procedures unless they are performed on an outpatient basis, and some private insurance companies offer 100% coverage for ambulatory surgery.

2. One of the major advantages of ambulatory surgery over inpatient surgery is the cost savings. However, a proliferation of underutilized ambulatory surgery facilities is undersirable as an alternative to inpatient surgery. Optimal utilization of each ambulatory surgery facility should take into account the following factors:

a. number of operating rooms available for ambulatory surgery;

b. maximum number of surgical procedures to be performed per operating room per workday;

c. annual number of days available for ambulatory surgery;

d. average length of time per operation;

e. recovery room capacity.

3. There are two voluntary accreditation organizations for ambulatory surgery facilities, the Joint Commission on Accreditation of Hospitals (JCAH) and the Accreditation Association for Ambulatory Health Care (AAAHC).

C. Service Area. The service area for ambulatory surgery facilities is the health planning district in which the facility (or proposed facility) is located.

D. Resource Goals

1. Dedicated ambulatory surgery facilities should perform a minimum of 5 surgeries per operating room per workday (250 days per year). For new dedicated ambulatory surgery facilities, projections should be based on physician's estimates of procedures to be performed in the facility; for existing dedicated ambulatory surgery facilities proposing expansion, projections should be based on and documented by actual utilization data and reasonable estimates of future utilization. The applicant must demonstrate that the existing facility performs a minimum of five procedures per operating room per workday, and will maintain the minimum standard with the proposed additional operating rooms.

2. Ambulatory surgery facilities should be no more than 10 road miles from an acute care general hospital.

3. An applicant proposing to construct a new ambulatory surgery facility or proposing major renovations for the provision of ambulatory surgery must propose to build/renovate no fewer than two operating rooms.

La. Admin. Code tit. 48, § I-11525

Promulgated by the Department of Health and Human Resources, Office of Management and Finances, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with P.L. 93-641 as amended by P.L. 96-79, and 36:256(b).