Sec. 10.09.02.05. Limitations

A. Services which are not covered are:

(1) Physician services not medically justified;

(2) Nonemergency dialysis services related to chronic kidney disorders unless they are provided in a Medicare-certified facility;

(3) Physician inpatient hospital services rendered during any period that is in excess of the length of stay authorized by the Utilization control agent (UCA);

(4) Physician services denied by Medicare as not medically necessary;

(5) Services which are investigational or experimental;

(6) Autopsies;

(7) Physician services included as part of the cost of an inpatient facility, hospital outpatient department, or free-standing clinics;

(8) Payment to physicians for specimen collections, except by venipuncture, and capillary or arterial puncture;

(9) Immunizations required for travel outside the continental United States;

(10) Injections, and visits solely for the administration of injections, unless medical necessity and the patient's inability to take appropriate oral medications are documented in the patient's medical records;

(11) Visits solely to accomplish one or more of the following:

(a) Prescription, drug or food supplement pick-up, collection of specimens for laboratory procedures,

(b) Recording of an electrocardiogram,

(c) Ascertaining the patient's weight;

(12) Interpretation of laboratory tests or panels;

(13) Medical Assistance prescriptions and injections for central nervous system stimulants and anorectic agents when used for weight control;

(14) Drugs and supplies dispensed by the physician which are acquired by the physician at no cost;

(15) Disposable medical supplies;

(16) Services prohibited by the Board of Physician Quality Assurance;

(17) Services which are provided outside the United States;

(18) Services which do not involve direct (face-to-face) patient contact;

(19) Sterilization reversal procedures;

(20) Prescriptions for drugs written on prescription pads that do not prevent copying, modification, or counterfeiting; and

(21) Physician-administered drugs from manufacturers that do not participate in the Federal Drug Rebate Program.

B. Preoperative evaluations for anesthesia are included in the fee for administration of anesthesia and the provider may not bill them as consultations.

C. Referrals from one physician to another for treatment of specific patient problems may not be billed as consultations.

D. The operating surgeon may not bill for the administration of anesthesia or for an assistant surgeon who is not in the operating surgeon's employ.

E. Payment for consultations provided in a multispecialty setting is limited by criteria established by the Department.

F. The Department will not pay a provider for those laboratory or x-ray services performed by another facility. The Department will pay directly the facility performing those services.

G. The Program does not cover services rendered to an inpatient before one preoperative inpatient day, unless preauthorized by the Program.

H. The provider may not bill the Program for services rendered under the supervising physician's provider number by an employed nonphysician extender, such as:

(1) A physical therapist;

(2) An occupational therapist;

(3) A speech language pathologist;

(4) An audiologist; or

(5) A nutritionist.