LAC 40:I.2713. Ambulatory Surgery

A. Ambulatory surgery refers to a program which recommends that specified surgical procedures be performed on an outpatient basis. The program is designed to reduce unnecessary hospitalizations and to shift care to less costly settings if medically appropriate. The surgeon is responsible for following the specified guidelines for procedures which should be performed in an outpatient setting. B. Ambulatory Surgery Procedures 1. The following is a list of surgical procedures and tests that are classified as primarily outpatient procedures not requiring hospitalization under normal circumstances. Arthroscopy | Brush Biopsy of Stomach Blood Transfusions | Carpal Tunnel Release Closed Reduction Nasal Fracture | Cystoscopy Closed Reduction of Dislocation or Fracture | Dx Radiological Procedures in Absence of Acute Admittable Illness Dx Ultrasound | Esophagoscopy Exploration Tendon Sheath―Hand | Excision Lesion Tendon Sheath―Hand Excision Lesion Tendon Sheath | Fiberoptic Bronchoscopy Flex Fiberoptic Colonoscopy | Gastroscopy Lid Reconstruction | Laryngoscopy/ Tracheoscopy Large Bowel Endoscopy | Laparoscopy Other Larynx Diagnostic Procedures | Other Fusion of Toe Other Skin and Subcutaneous Incision/Drainage | Other Local Destruction of Skin Peripheral Nerve Biopsy | Plastic Repair External Ear Partial Ostectomy | Sinus Puncture for Lavage Surgical Tooth Extraction | Small Bowel Endoscopy―via existing surgical ostomy Skin Incision and Foreign Body Removal | Skin and Subcutaneous Biopsy Skin Suture | Tooth Extraction Turbinate Fracture | Tenotomy of Hand Total Ostectomy―Digit | Turbinectomy by Diathermy/Cryosurgery The Office of Workers' Compensation may expand this list pursuant to its rulemaking authority. 2. The carrier/self-insured employer should not waive ambulatory surgeries except on the basis of defined criteria, which must include at least the following: a. presence of other documented medical problems that make prolonged pre-operative or post-operative observation medically necessary; b. inability to provide proper post-operative care at home; and c. likelihood that another major surgical procedure might follow the initial procedure. 3. The carrier/self-insured employer should have an automated system for administering program requirements and documenting provider compliance with the program. C. Ambulatory Surgery Preparation 1. Preparation a. It is important to stress to the provider that the intent of the program is not to reduce the quality of care and to explain that carrier/self-insured employer consultant physicians are available to discuss cases for which the attending physician feels the surgery must be performed on an inpatient basis. b. Drawing on the strength of existing physician relations, the carrier/self-insured employer needs to stress continued cooperation between the carrier/self-insured employer physician consultant and the attending physician. In addition, the carrier/self-insured employer should develop ongoing physician communications, such as newsletters and attendance at community physician gatherings. 2. Implementation a. Telephone Inquiry Service. Telephone numbers should be published in educational materials and standard form letters to physicians and claimants. This telephone service should provide for prompt response to inquiries regarding ambulatory surgery. b. Appropriate Staff and Documentation. Registered nurses and physicians are the recommended staff for processing of ambulatory surgery requests and inquiries. Procedures must be available for timely review of cases which providers believe cannot be safely performed in an outpatient setting. Program procedures should be routine and documented. 3. Evaluation a. Data Collection. Ambulatory surgery information should be linked to the claims system to properly process surgical claims. Ambulatory surgery elements should be retrievable on a claim-by-claim basis for compilation and classification of activity performance. b. Plan Data Reporting. Carriers will be required to collect data for report preparation as outlined in the billing and maintenance section of the Office of Workers' Compensation Reimbursement Manual.