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Library: Policy

317:30-5-8. Surgery

Revised 7-25-08

(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.

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