5101:3-12-04 Home health and private duty nursing: visit policy.

Reimbursement of home health services or private duty nursing (PDN) in accordance with this chapter is on a per visit basis.

(A) A "visit" is the duration of time that a covered home health service or private duty nursing service is provided in a face to face encounter to one or more medicaid consumer(s) at the same residence on the same date during the same time period; and

(1) Begins with the provision of a covered service and ends when the face to face encounter ends; and

(2) Must have a lapse of time of two or more hours between any previous or subsequent visit for the provision of the same covered service unless the length of a private duty nursing visit requires an agency to provide a change in staff; and

(3) Must have a lapse of two or more hours between the provision of home health nursing or private duty nursing service.

(B) When a consumer is enrolled in a home and community based services (HCBS) waiver and is receiving consecutive home health or PDN service(s) with waiver service(s) that have the same scope of service, there must be a lapse of time of two or more hours between the services. A "scope" of a service includes the definition of the service and the conditions that apply to its provision and the provider who renders the service(s).

(C) Each covered visit must be billed:

(1) As a separate line item. The number of lines/procedure codes must reflect the number of visits provided with one line equaling one visit.

(2) To reflect the length of the visit where one unit equals fifteen minutes. Units must be rounded down if the number of minutes is seven or less and rounded up if over seven minutes.

(D) A "group visit" is a visit where the service(s) is provided to more than one person. During a group visit:

(1) The ratio of an individual provider or an employee of a provider to the people being served may never exceed one to three.

(2) An entire visit is considered a group visit even if only a portion of the visit met the definition of a group visit.

(3) A modifier HQ must be used when billing for a group visit to identify each group setting in accordance with rule 5101:3-12-05 of the Administrative Code.

(E) A "multiple visit" is when the provision of the same home health service or PDN by the same provider occurs on the same date of service for the same consumer separated by a lapse of two hours. Multiple visits must be medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code due to the functional limitations and/or medical condition of the consumer as documented in the plan of care, and if the consumer is enrolled in HCBS waiver, the services plan or all services plan. Documentation must support the medical need for multiple visits. After the initial visit multiple visits must either be billed with a U2 modifier for the second visit or U3 for the third or any subsequent visit.

Replaces: Part of 5101:3-12-06, 5101:3-12-10

Effective: 07/01/2006
R.C. 119.032 review dates: 07/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.85
Prior Effective Dates: 4/7/77, 5/1/87, 4/1/88, 5/15/89, 3/30/90 (Emer), 6/29/90, 7/1/90, 3/12/92 (Emer), 6/1/92, 7/31/92 (Emer), 10/30/92, 4/30/93 (Emer), 7/1/93 (Emer), 7/30/93, 9/1/93, 1/1/96, 7/1/98, 9/29/00, 9/1/05