1. 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.

2. B. Ambulatory Surgery Procedures

   1. 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. 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:

      1. a. presence of other documented medical problems that make prolonged pre-operative or post-operative observation medically necessary;
      2. b. inability to provide proper post-operative care at home; and
      3. c. likelihood that another major surgical procedure might follow the initial procedure.
   3. 3. The carrier/self-insured employer should have an automated system for administering program requirements and documenting provider compliance with the program.

3. C. Ambulatory Surgery Preparation

   1. 1. Preparation

      1. 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.
      2. 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. 2. Implementation

      1. 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.
      2. 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. 3. Evaluation

      1. 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.
      2. 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.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991).