5101:3-29-04 Billable services.

(A) Billable encounters, general provisions -- For purposes of the outpatient health facility program, an "encounter" is defined as a face-to-face contact between a patient and a health professional whose services are covered under the medicaid program. For a health service to be defined as an encounter, it must meet the definitions set forth in this paragraph and must be recorded in the patient's health record. Services must be billed on an encounter basis. The types of encounters are defined in paragraph (B) of this rule. When an encounter is billed, also provide a detailed code listing on subsequent lines of the claim which describes all services provided to the patient during that encounter.

(1) Multiple encounters with the same health professional that take place on the same day constitute a single billable encounter except for cases in which the patient, subsequent to the first encounter, suffers illness or injury requiring additional diagnosis and treatment.

(2) Multiple encounters with different health professionals that take place on the same day for the same illness or injury constitute a single billable encounter.

(3) To meet the encounter criterion, the professional must be acting independently and not assisting another professional. For example, a nurse assisting a physician during a physical examination by taking vital signs, taking a history, or drawing a blood sample is not credited with a separate encounter. A nurse who, utilizing standing orders or protocol, sees a patient to monitor physiological signs, provide medication renewal, etc., without the patient routinely seeing the physician at the same time, is credited with an encounter. The definitions of independent nursing encounters can be found in paragraph (B)(1)(c) of this rule.

(4) An encounter for the purpose of providing services such as drawing blood, collecting urine specimens, or providing a medical supply to the patient during the visit are not considered a medical encounter but are bundled into the appropriate encounter type. For example collecting a urine specimen would be bundled into a laboratory encounter.

(5) Billable encounters are limited to:

(a) Those which take place at the site approved for participation in the outpatient health facility program; or

(b) Those medical service encounters which take place in the hospital or the patient's home for the purpose of providing services to outpatient health facility (OHF) patients who are hospitalized or temporarily confined to their home.

(6) Encounters with individuals involved with another patient (e.g., conferences or consultations with a family member) are not billable unless such individual is independently eligible for medicaid and receives services for diagnosis and/or treatment of an illness or injury. An encounter, for example, with a family member to discuss the diagnosis and/or treatment of a child who is not present cannot be billed. A conference with family members which occurs in the course of diagnosis and/or treatment of the eligible child would be covered as a service incidental to the treatment rendered; i.e., one billable service provided to both the child and family members.

(7) The encounter criterion is not met nor is coverage available under medicaid for cost involved in the following circumstances:

(a) When a provider participates in a community meeting or group session which is not designed to provide health services to program users. Examples of such activities include orientation sessions for new patients, health presentations to community groups (high school classes, PTA, etc.), and information presentations about the program.

(b) When the only health service provided is part of a large scale effort such as a mass immunization program, screening program, or community-wide service program (for example, a health fair).

(B) Billable encounter definitions

(1) "Medical encounter" is an encounter between a medical provider and a patient for the purpose of diagnosis and/or treatment of an illness or injury, including surgery. Preventive medicine services are covered in accordance with rule 5101:3-4-34 of the Administrative Code. Included in this category are physician encounters, mid-level practitioner encounters, and independent nursing encounters. Pregnancy prevention/contraceptive management services, defined in accordance with rule 5101:3-21-02 of the Administrative Code, are included under the definition of medical encounter.

(a) "Physician encounter" is an encounter between a physician or podiatrist and a patient. For purposes of this program, encounters between an ophthalmologist or a psychiatrist and a patient are included in this category as medical encounters.

(b) "Mid-level practitioner encounter" is an encounter between a physician assistant or advanced practice nurse and a patient in which the mid-level practitioner is the independent provider of a medical service.

(c) "Nursing encounter" is an encounter between a registered nurse or licensed practical nurse and a patient in which the nurse is acting independently and provides a nursing service. The service may be provided under standing orders of a physician, under specific instructions from a previous visit, or under supervision of a physician who has no direct contact with the patient during a visit. Examples of independent nursing encounters include:

(i) Administration of immunizations;

(ii) Injections (including allergy injections);

(iii) Dressing changes;

(iv) Suture removal.

(v) The supply visit for hormonal contraceptives (if blood pressure, weight, and/or other vital signs are taken); and

(vi) The return visit following insertion of an intrauterine device.

(2) "Dental encounter" is an encounter between a dentist or dental hygienist/oral therapist under the supervision of a dentist and a patient for provision of covered dental services. All dental hygienist or oral therapist services are included under this encounter definition.

(3) "Mental health encounter" is an encounter between a licensed psychologist or a licensed independent social worker and a patient for the provision of covered psychological services. A mental health encounter may also include mental health services provided by licensed social workers in accordance with rule 5101:3-4-29 of the Administrative Code.

(4) "Vision care encounter" is an encounter between an optometrist or optician and a patient for the provision of covered vision care services.

(5) "Speech and hearing encounter" is an encounter between an audiologist or speech pathologist and a patient for the provision of covered speech and hearing services. For purposes of the OHF program, providers shall report the numbers of individual speech and hearing procedures, in addition to speech and hearing encounters. Such reporting shall enable ODJFS to apply the speech and hearing visit limitation policy defined in paragraph (B)(3) of rule 5101:3-29-03 of the Administrative Code.

(6) "Physical medicine encounter" is an encounter between a physician, physical therapist, or a mechanotherapist and a patient for receipt of a covered physical medicine service. For purposes of the OHF program, providers will be reporting the numbers of individual physical medicine procedures in addition to physical medicine encounters. Such reporting will enable the ODJFS to apply the physical medicine procedure limitation policy defined in paragraph (B)(5) of rule 5101:3-29-03 of the Administrative Code.

(7) "Laboratory encounter" is an encounter between a medical professional and a patient to provide one of more laboratory procedures including specimen collection. Covered laboratory tests are identified in Chapter 5101:3-11 of the Administrative Code.

(8) "Radiology encounter" is an encounter between a medical professional and a patient to provide one or more x-ray procedures covered under medicaid as described in rule 5101:3-4-25 of the Administrative Code.

(9) "Transportation encounter" shall be billed on a unit basis. Each trip from the service site shall be counted as a unit of transportation. In order to meet the definition of a billable transportation unit of service, the transportation must be provided on the same date that another billable encounter or unit of service occurs.

(C) Medical supplies and drugs

(1) Medical supplies used as part of the visit are considered part of the medical encounter i.e., are incidental to a service provided (e.g., bandages, dressings, and adhesive) are to be included as cost items for purposes of prospective rate determination. Those items which are given to the patient to be used at home (e.g. contraceptive supplies, colostomy supplies) are to be billed and reimbursed according to provisions governing reimbursement for the medical supplier program described in Chapter 5101:3-10 of the Administrative Code. Types of medical supply items which are included as cost items cannot be billed separately under the medical supplier program.

(2) Drugs which are given as part of the visit at the facility are considered part of the medical encounter. Drugs that are dispensed for take-home use are considered a pharmacy service and are to be billed and reimbursed according to provisions governing coverage of drugs as set forth in Chapter 5101:3-9 of the Administrative Code.

(D) Contracted services -- It is recognized that OHFs may wish to augment staff-delivered services through contractual arrangements. Under the OHF program, services provided by contract must be provided on-site in order to be included as a cost item in determining the prospective rate. At the option of each participating OHF, services other than those required under paragraph (E)(1)(e) of rule 5101:3-29-01 of the Administrative Code may be provided on-site or off-site. When the services are provided at locations other than the location at the approved site, the contractor must bill these services to the ODJFS if the contractor participates in the medicaid program. Examples of other services may include physical therapy, speech therapy, dental services, or laboratory or X-ray services which are in addition to those listed in paragraph (E) of rule 5101:3-29-01 of the Administrative Code. The laboratory and X-ray services listed in paragraph (E) of rule 5101:3-29-01 of the Administrative Code must be provided on-site except as stated in paragraph (B) of rule 5101:3-11-04 of the Administrative Code.

Contracts for services required under paragraph (E) of rule 5101:3-29-01 of the Administrative Code and contracts for any additional services to be included in the prospective rate must stipulate that the OHF retains all authority and responsibility for patient care. The execution of a contract with another party does not terminate the legal responsibility of the qualified OHF to the ODJFS to assure that all program requirements are met and that all provisions of the provider agreement as set forth in rule 5101:3-1-17.2 of the Administrative Code are met.

Contracts pertaining to services must specify that the OHF assumes professional and administrative responsibility for the services rendered. In order for contractual arrangements to be recognized, OHFs must provide the following information to the ODJFS at the point of entry into the program and at any subsequent point when new contracts are negotiated or when existing contracts are revised:

(1) Identification by name and, where applicable, medicaid provider number of each individual practitioner providing services under contractual arrangements. Where the contract is let with a legal entity other than the individual practitioner, both the name of the legal entity and the names of any individual practitioners involved must be furnished.

(2) A written statement indicating, for each legal entity or individual practitioner, whether the contracted services are:

(a) To be included as a cost item and reimbursed under the applicable prospective rate assigned to the outpatient health facility; or

(b) To be billed independently by the legal entity or individual practitioner under contract.

(E) The following types of services must be billed by the OHF under a separate medicaid provider number since the cost-based rates for OHFs do not apply to these services:

(1) Claims for medicare crossover payments; and

(2) Claims for services provided to disability assistance patients.

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.04
Prior Effective Dates: 11/10/83, 10/1/87, 4/18/88, 11/1/01, 5/1/05