Section 1221.58. Limitations on payment

The following limits apply to payment for compensable services:

(1) Prenatal visits shall be limited to 12 per pregnancy. Complications attributable to pregnancy may not be counted as part of the 12 prenatal visits but are classified for invoicing purposes as acute illness.

(2) The physician’s component for an emergency room visit may be either an emergency room physician’s service fee, emergency or nonemergency or the fee for a specific compensable procedure. No payment may be made for the emergency room physician’s service fee if a specific compensable procedure is billed for the same emergency room visit. Only those services noted in § 1221.51(7) (relating to general payment policy) shall be compensable in addition to either the emergency room physician’s service fee or the fee for a specific compensable procedure. Two or more specific compensable surgical procedures performed at the same time shall be paid in accordance with § 1221.51(8).

(3) The flat visit fee shall not be paid if a specific compensable procedure is billed for the same hospital, medical school or independent clinic visit. Only those services noted in § 1221.51(7) shall be compensable in addition to either the flat visit fee or fee for specific compensable procedure. Two or more specific compensable surgical procedures performed at the same time shall be paid in accordance with § 1221.51(8).

(4) Payment for physicians’ services performed in a hospital clinic, medical school clinic, independent clinic or hospital emergency room shall be subject to the limitations and provisions of Chapter 1141 (relating to physicians’ services).

The provisions of this § 1221.58 adopted December 5, 1980, effective December 1, 1980, 10 Pa.B. 4599; amended December 23, 1983, effective January 1, 1983, 13 Pa.B. 3932. Immediately preceding text appears at serial page (58138).