Okla. Admin. Code § 317:30-5-8

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-8 - Surgery

(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.

Okla. Admin. Code § 317:30-5-8

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253, the 2-1-07 emergency amendments to this section 317:30-5-8 were scheduled to expire on 7-15-07, if not already superseded by a permanent action or by another emergency action(s) that retained the same 7-15-07 expiration date.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.