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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1806 (March 30, 2024).

55 Pa. Code § 1150.56. Medical services.

§ 1150.56. Medical services.

 (a)  Inpatient medical care.

   (1)  On any given day, a pracitioner may bill for only one of the following:

     (i)   An initial comprehensive visit.

     (ii)   An initial limited visit.

     (iii)   Prolonged medical attention.

     (iv)   A consultation.

     (v)   A surgical procedure.

     (vi)   An inpatient hospital visit.

     (vii)   An Early and Periodic Screening, Diagnosis, and Treatment visit.

     (viii)   Stand-by services for high risk deliveries or Cesarean sections.

   (2)  Medical visits are not paid to the same practitioner who performs the surgery.

   (3)  Only one practitioner is eligible to receive payment for medical care for the same patient on the same day.

   (4)  A practitioner who provides medical care may also bill for medical diagnostic procedures, surgical diagnostic procedures, and radiation therapy for the same patient during the same period of hospitalization.

   (5)  During a period of hospitalization, payment may be made to one other practitioner responsible for inpatient medical care, if provided, in addition to the practitioner billing for surgical services.

   (6)  Payment for consultation is limited to two consultations provided the same patient during the same period of hospitalization.

 (b)  Nonhospital medical care.

   (1)  A practitioner may bill the Department for medical care provided to an outpatient as an office visit, a skilled nursing or intermediate care facility visit, or a home visit.

   (2)  In addition to a medical care visit, a practitioner may bill for diagnostic radiology procedures, medical diagnostic procedures, surgical diagnostic procedures, nuclear medicine procedures and radiation therapy.

   (3)  On any given day, a practitioner may bill for only one of the following per recipient:

     (i)   An initial visit in a skilled or intermediate nursing facility.

     (ii)   A medical visit.

     (iii)   An office visit.

     (iv)   A consultation.

     (v)   A surgical procedure.

     (vi)   An EPSDT visit.

     (vii)   A general medical examination.

   (4)  For any home visit, a practitioner may bill for no more than two patients.

   (5)  A practitioner may bill for services performed in an emergency room only in accordance with the arrangement selected by the hospital as specified in Chapter 1221 (relating to clinic and emergency room services) and stated in a letter directed to and approved by the Office of Medical Assistance, Bureau of Provider Relations. Arrangements may not be changed without prior written agreement with the Bureau of Provider Relations.

   (6)  A visit to a practitioner’s office or a hospital outpatient department solely for the purpose of receiving a diagnostic service, administration of chemotherapy, or for an injection of medication or vaccine does not qualify for payment as an office visit, a hospital clinic emergency room visit or for a visit for support services. In this kind of situation, payment will be made only for the diagnostic service, the administration of chemotherapy, or for the injection of medication or vaccine. Payment to a practitioner or hospital outpatient department for a visit includes payment for administering any injections of medication or vaccine.


   The provisions of this §  1150.56 adopted January 7, 1983, effective January 1, 1983, 13 Pa.B. 305; amended October 28, 1983, effective January 1, 1984, 13 Pa.B. 3303. Immediately preceding appears at serial pages (79173) and (79174).

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