Chapter 5101:3-4 Physician Services

5101:3-4-01 Eligible providers of physician services.

(A) Definitions.

(1) “Physician” means an individual currently licensed under state of Ohio law or under another state’s law to practice medicine and surgery or osteopathic medicine and surgery. Interns and residents are explicitly excluded from the definition of “physician” and are covered as a part of hospital services. This exclusion applies whether or not the intern or resident may be authorized to practice as a physician under the laws of the state in which he/she performs services. Residents having a staff or faculty appointment or designated as a “fellow” are also excluded from the definition of physician.

(2) “Physician group practice” means a group composed solely of two or more physicians defined in paragraph (A) of this rule who are enrolled in the medicaid program as individual providers for the purpose of providing physician services.

A “physician group practice” may include a group legally authorized and organized to engage in the practice of medicine and surgery or osteopathic medicine and surgery through one of the following arrangements:

(a) A corporation formed under division (B) of section 1701.03 of the Revised Code;

(b) A limited liability company formed under Chapter 1705. of the Revised Code;

(d) A nonprofit corporation;

(e) A foundation; or

(f) A professional association formed under Chapter 1785. of the Revised Code with the following limitations:

(i) Medicaid’s definition of a “physician group practice” specifically does not include a professional association that is a combination of professional services as set forth in division (B) of section 1785.01 of the Revised Code that includes a combination of optometrists, chiropractors, psychologists, registered or licensed practical nurses, pharmacists, physical therapists, mechanotherapists, doctors of podiatric medicine and surgery, and doctors of medicine and surgery, or osteopathic medicine and surgery; or

(ii) Medicaid’s definition of “physician group practice” does not include combinations of physicians of medicine and surgery or osteopathic physicians of medicine and surgery with any other professionals specified in division (A) of section 1785.01 of the Revised Code.

(iii) However, for purposes of the medicaid program, “physician group practice” does include a combination of doctors of medicine and surgery and doctors of osteopathic medicine and surgery.

(3) “Provider-based physician” means any physician who is under the fiscal, administrative and professional control of a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility or other medicaid participating provider through an employment, a contractual or other legally binding arrangement to provide hospital (or provider) services in addition to the professional services he or she provides directly to, or for the benefit of, individual hospital (provider) patients.

(B) Physicians as defined in paragraphs (A) (1) and (A)(2) of this rule are eligible to participate in Ohio’s medicaid program and provide covered physician services upon execution of the standard Ohio medicaid provider agreement.

(C) Physicians licensed under another state’s law to practice medicine and surgery or osteopathic medicine and surgery are eligible to participate in Ohio’s medicaid program and provide covered physician services as long as:

(1) The services are rendered to eligible Ohio recipients in the state in which the provider is licensed to practice; and

(2) The provider of physician services has a currently valid provider agreement with the department.

(D) Eligible providers of physician services also include the following Ohio medicaid providers:

(1) Ambulatory health care centers (clinics) as defined in Chapter 5101:3-13 of the Administrative Code;

(2) Rural health facilities (RHF) as defined in Chapter 5101:3-16 of the Administrative Code;

(3) Outpatient health facilities (OHF) as defined in Chapter 5101:3-29 of the Administrative Code; and

(4) Federally-qualified health centers (FQHC) as defined in Chapter 5101: 3-28 of the Administrative Code.

(E) Provider-based physician.

(1) A provider-based physician may be reimbursed for services rendered directly to, or for the benefit of, individual patients, if the following requirements are met:

(a) The services are personally furnished for an individual patient by a physician who is enrolled as an Ohio medicaid provider;

(b) The services contribute directly to the diagnosis or treatment of an individual patient;

(d) In the case of anesthesiology, laboratory, or radiology services, the additional requirements in rules 5101:3-4-21 and 5101:3-4-25 of the Administrative Code; and

(e) The portion of the expenses associated with the provision of the service are excluded from the hospital or provider-based cost report.

(2) Services provided by a provider-based physician including teaching; research; administration; supervision of professional or technical personnel; supervision of residents, interns, or fellows; service on provider committees; and other provider-based activities that are of benefit to patients generally are reimbursable only as a hospital (provider) service to the hospital (provider) payments for these services provided at hospitals are bundled into the hospital inpatient or outpatient facility payment in accordance with Chapter 5101:3-2 of the Administrative Code. Payments for services provided at another provider-based practice are included in the payment made to the employing or contacting provider.

(3) Services provided by provider-based physicians are reimbursable only to the employing or contracting provider.

(F) Nothing in this rule precludes physician group practices as defined by medicaid in paragraph (A)(2) of this rule from employing other practitioners.

Effective: 09/01/2005

R.C. 119.032 review dates: 06/06/2005 and 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 10/1/83 (Emer), 12/29/83, 9/1/89, 3/26/01

5101:3-4-02 Scope of coverage.

(A) Direct and general physician supervision.

(1) “Direct supervision” in the physician’s office, group practice, or clinic setting means that the physician must be present in the office suite throughout the time the nonphysician is providing the service and immediately available to provide assistance and direction throughout the time the nonphysician is performing services. Direct supervision does not mean the physician must be in the same room while the nonphysician is providing services. The availability of the physician by telephone or the presence of the physician somewhere in the institution does not consitute direct supervision.

(2) “General supervision” means that the physician is available, but not necessarily present in the office suite or clinic, to provide those medical services which constitute the practice of medicine and surgery as defined under section 4731.34 of the Revised Code. However, if the physician is not physically present in the office suite he/she must be immediately available to the nonphysician for consultation purposes by telephone and within a thirty-mile radius of the office.

(B) Services performed under direct supervision

(1) The department will reimburse an eligible provider of physician services for covered physician services personally provided by the physician or by a nonphysician (e.g., nurse, etc.) under the direct supervision of the physician unless otherwise stated in other rules in Chapter 5101:3-4 of the Administrative Code.

(2) Services provided under direct supervision are covered only if the following conditions are met:

(a) The nonphysician personnel involved in performing the service must meet the following requirements:

(i) The nonphysician must be a part-time, full-time or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician or the nonphysician must be an independent contractor engaged by the physician through a written agreement; and

(ii) If the nonphysician is a leased employee or independent contractor, the physician or legal entity exercises control over the actions taken by the nonphysician personnel with regard to the rendering of medical services to the same extent as the physician would exercise if the leased employee or contractor was an employee of the physician or legal entity.

(b) The service must represent an expense to the physician or legal entity;

(d) The service must be furnished in connection with a covered physician service which was billed to the department. Therefore, the patient must be one who has been seen by the physician; and

(e) There must have been a personal professional service furnished by the physician to initiate the course of treatment on which the service being performed is an incidental part. In addition, there must be subsequent services by the physician of a frequency that reflects his/her continuing participation in the management of the course of treatment.

(1) Services provided under general supervision are covered only if the following conditions are met:

(a) The nonphysician personnel involved in performing the service must meet the following requirements:

(i) The nonphysician must be a part-time, full-time or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician, or the nonphysician must be an independent contractor engaged by the physician through a written agreement; and

(b) The service must represent an expense to the physician or legal entity.

(2) The department will reimburse an eligible provider of physician services for the following services provided under the general supervision of the physician by nonphysicians:

(a) Early and periodic screening, diagnosis, and treatment (EPSDT, also known as healthchek) program services provided by a registered nurse with significant training and/or experience in the field of pediatrics;

(b) Pregnancy related services as detailed in rule 5101:3-4-10 of the Administrative Code;

(d) Physician services provided by a rural health facility (RHF), federally qualified health center (FQHC) or outpatient health facility (OHF);

(e) Minimal office visits as defined in the “Physicians’ Current Procedural Terminology” (CPT).”CPT” as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code;

(f) Family planning visits as defined in rule 5101:3-4-07 of the Administrative Code;

(g) Allergy injections administered by a properly instructed person in accordance with the physician’s prescribed plan of treatment;

(h) Services for the diagnosis and treatment of mental and emotional disorders provided by clinical social workers, and professional clinical counselors in accordance with rule 5101:3-4-29 of the Administrative Code. Services provided by licensed social workers and professional counselors must meet the supervision and documentation provisions specified in rule 5101:3-4-29 of the Administrative Code; and

(i) Physician services provided by public health department clinics, rehabilitation clinics, or family planning clinics.

(D) When services are provided by nonphysicians, the services rendered must be within the nonphysician’s scope of licensure (if licensure is required) or a service for which the nonphysician is legally authorized to provide under Ohio law and documented in the patient’s medical records. Services provided by nonphysicians may not be the type of services which constitute the practice of medicine and surgery as defined under section 4731.34 of the Revised Code.

(E) Except as provided in paragraph (F) of this rule, the following provisions apply:

(1) Services rendered by non-physicians falling under paragraph (C) (2) of this rule must be provided under general supervision;

(2) Other services not falling under paragraph (C) (2) of this rule provided by non-physicians must be provided under direct supervision as described in paragraph (B) of this rule; and

(3) When services are provided by non-physicians, patients’ records must be reviewed and countersigned by the supervising physician.

(F) Services provided by non-physicians who have their own provider category/type (e.g. clinical psychologists, advanced practice nurses, and physical therapists) and are employed by or under contract with a physician’s office are not subject to the physician supervision provisions described in this rule. However, a physician’s office may not act simply as a billing agent for a non-physician such as a clinical psychologist. The conditions described in paragraph (C) (1) of this rule must be met in order for the services of a non-physician such as clinical psychologist to be covered as a physician service. The non-physicians listed in this paragraph are restricted to the coverage provisions and limitations for their respective provider type. Note that chiropractic services are not covered for adults in any setting effective for services rendered on and after January 1, 2004.

(G) Eligible providers of physician services may not be reimbursed for physician services provided in a long-term care facility (LTCF), inpatient hospital, outpatient hospital, or emergency room by nonphysicians employed by the hospital or LTCF, even though the physician ordered the services.

HISTORY: Eff 4-7-77; 12-21-77; 12-30-77; 1-8-79; 2-1-80; 5-19-86; 7-1-87; 4-1-88; 9-1-89; 2-17-91; 4-1-92 (Emer.); 7-1-92; 5-2-94 (Emer.); 7-1-94; 1-1-01; 1-2-04 (Emer.); 4-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02

RC 119.032 review dates: 8/11/00, 8/11/05, 1/16/04, 4/1/09

5101:3-4-02.1 "By-report" services.'.

(A) A “by-report service” is any service requiring manual review by the department to determine one or all of the following: if the service is a covered service; the reimbursement rate on an unpriced procedure; or if special conditions or requirements were met.

(B) All covered services or procedures not listed under a specific HCPCS code in appendix DD of rule 5101:3-1-60 of the Administrative Code must be billed under one of the unlisted CPT codes by-report. Additionally, there are specific services or conditions designated in Chapter 5101:3-4 of the Administrative Code as requiring “by-report” billing.

(C) Upon completion of a by-report service, a claim must be submitted to the department along with the information required for payment of that service. A report documenting the services or procedures rendered, specific methodology or treatment programs, and medical history and indications must be provided at a minimum. All attachments submitted with the claim must meet the requirements specified in Chapter 5101:3-1 of the Administrative Code.

(D) Coverage and reimbursement for by-report services will be determined by the department on a case-by-case basis.

R.C. 119.032 review dates: 04/29/2004 and 04/29/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 5/19/86, 7/1/87, 4/1/88, 9/1/89, 1/1/01

5101:3-4-02.2 Site differential payments and place of service.

(A) Site differentials

(1) Based on the site of service, the medicaid maximum payment will vary for the services identified in appendix A to this rule.

(2) This variance in payment shall be referred to as the site differential.

(3) When the services identified in appendix A to this rule are provided in a hospital setting (i.e., inpatient, outpatient or emergency department), the maximum reimbursement will be the lesser of the provider’s billed charge or a percentage of the medicaid maximum as set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(4) The site differential percentages are listed in appendix A to this rule.

(B) Place of service codes

(1) The following place of service codes affect payment and must be entered on the billing invoice:

(a) The place of service code assigned to “office” must be entered when the service is provided in a physician’s office or group practice office and the office is not a part of an outpatient hospital facility. A physician’s office or group practice is considered a part of an outpatient hospital facility if the hospital bills the department on a UB-92 invoice for hospital services provided in conjunction with the physician’s services.

(b) The place of service code assigned to “home” must be entered when the service is rendered to a patient in the patient’s place of residence except when the patient’s place of residence is a long-term care facility.

(c) The place of service code assigned to “hospital” must be entered when the service is provided to an inpatient hospital patient as defined in Chapter 5101:3-2 of the Administrative Code.

(d) The place of service code assigned to “outpatient hospital” must be entered when the service is provided by a physician or a clinic provider and the hospital bills the department on a UB-92 invoice for hospital services provided in conjunction with the physician’s services.

(e) The place of service code assigned to “emergency room” must be entered when the service is provided in a hospital emergency room department whether the physician is an emergency room staff physician or not.

(f) One of the place of service codes assigned to “clinics” must be entered in accordance to the type of clinic when the service is rendered in a facility that meets the department’s definition of a clinic, the facility possesses a provider number designated with the provider type “clinic” and the clinic is not a part of an outpatient hospital facility. A clinic is considered a part of an outpatient hospital facility if the hospital bills the department on a UB-92 invoice for hospital services provided in conjunction with clinic services.

(g) The place of service code assigned to “ambulatory surgery centers” must be entered when the service is provided in an ambulatory surgery center that possesses a provider number designated with the provider type ambulatory surgery center.

(h) One of the place of service codes assigned to long-term care facilities including skilled nursing facilities, nursing facilities, custodial care facilities or intermediate care/mentally retarded facilities must be entered when the service is provided in a long-term care facility.

(i) The appropriate place of service code must be entered when the service is provided in a setting not meeting any of the service locations designated in paragraphs (B)(1)(a) to (B)(1)(h) of this rule and a specific code has been assigned for that location.

(j) The place of service code assigned to “other, unlisted facility” must be entered if a specific place of service code has not been assigned for that location.

(2) Additional place of service codes may be found in the billing instructions at: http://emanuals.odjfs.state.oh.us/emanuals/medicaid)BIN.1001. (05/23/2007).

(C) Except as specified in this rule and elsewhere in Chapter 5101:3-4 of the Administrative Code, the payment for most physician services is the same regardless of the place of service. When the physician payment rate is dependent on the place of service reported, errors in reporting the place of service may result in an overpayment to the provider. 5101:3-4-02.2 2

(1) If a postpayment review of a physician’s records reveals that the physician reported the wrong place of service, the provider will be informed of this error and requested to correctly report the place of service on all claims submitted to the department in the future; and

(2) If the error resulted in an overpayment, the department will recoup the overpayment.

APPENDIX A

CODE DEFINITION PERCENT

99201* OFFICE/OP VISIT, NEW 80%

99202* OFFICE/OP VISIT, NEW 80%

99203* OFFICE/OP VISIT, NEW 80%

99204* OFFICE/OP VISIT, NEW 80%

99205* OFFICE/OP VISIT, NEW 80%

99211* OFFICE/OP VISIT, ESTABLISHED 80%

99212* OFFICE/OP VISIT, ESTABLISHED 80%

99213* OFFICE/OP VISIT, ESTABLISHED 80%

99214* OFFICE/OP VISIT, ESTABLISHED 80%

99215* OFFICE/OP VISIT, ESTABLISHED 80%

99241 OUTPATIENT CONSULT, NEW/ESTABLISHED 80%

99242 OUTPATIENT CONSULT, NEW/ESTABLISHED 80%

99243 OUTPATIENT CONSULT, NEW/ESTABLISHED 80%

99244 OUTPATIENT CONSULT, NEW/ESTABLISHED 80%

99245 OUTPATIENT CONSULT, NEW/ESTABLISHED 80%

90801 PSYCHIATRIC DIAGNOSTIC INTERVIEW 80%

90802 INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW 80%

90804 INDIVIDUAL PSYCHOTHERAPY 20 TO 30 MINUTES 80%

90805 WITH MEDICAL EVALUATION AND MANAGEMENT 80%

90806 INDIVIDUAL PSYCHOTHERAPY 45 TO 50 MINUTES 80%

90807 WITH MEDICAL EVALUATION AND MANAGEMENT 80%

90808 INDIVIDUAL PSYCHOTHERAPY 75 TO 80 MINUTES 80%

90809 WITH MEDICAL EVALUATION AND MANAGEMENT 80%

90810 INTERACTIVE PSYCHOTHERAPY 20 TO 30 MINUTES 80%

90811 WITH MEDICAL EVALUATION AND MANAGEMENT 80%

90812 INTERACTIVE PSYCHOTHERAPY 45 TO 50 MINUTES 80%

90813 WITH MEDICAL EVALUATION AND MANAGEMENT 80%

90814 INTERACTIVE PSYCHOTHERAPY 75 TO 80 MINUTES 80%

90815 WITH MEDICAL EVALUATION AND MANAGEMENT 80%

90845 PSYCHOANALYSIS 80%

90846 FAMILY PSYCHOTHERAPY (W/O PATIENT PRESENT) 80%

90847 FAMILY PSYCHOTHERAPY (PATIENT PRESENT) 80%

90849 MULTIPLE-FAMILY GROUP PSYCHOTHERAPY 80%

90853 GROUP PSYCHOTHERAPY 80%

90857 INTERACTIVE GROUP PSYCHOTHERAPY 80%

90862 PHARMACOLOGIC MANAGEMENT 80%

These codes may be used with the TH modifier and will also be reimbursed at 80%.

Effective: 07/01/2008

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 5/25/91, 4/1/92 (Emer), 7/1/92, 5/2/94 (Emer), 7/1/94, 1/1/01, 9/1/05

5101:3-4-03 Physician assistants.

(A) “Physician assistant” means a skilled person qualified by academic and clinical training to provide services to patients as a physician assistant in accordance with Chapter 4730. of the Revised Code under the supervision and direction of one or more physicians who are responsible for the physician assistant’s performance.

(B) Coverage and limitations

(1) Services/procedures provided by a physician assistant under the supervision and direction of his/her supervising physician(s) are covered if:

(a) The services are listed as standard functions for a physician assistant approved by the state medical board as described in rule 4731-4-01 of the Administrative Code with the exception of the service listed in paragraph (C)(4) of this rule; or

(b) The services have been approved by the state medical board as supplemental functions for that physician assistant as described in rule 4731-4-02 of the Administrative Code;

(c) The physician assistant is employed by or under contract with an eligible provider of physician services as described in rule 5101:3-4-01 of the Administrative Code; and

(d) The services described in both paragraphs (B)(1)(a) and (B)(1)(b) of this rule must be a covered service by the department as indicated in rule 5101:3-1-60 of the Administrative Code.

(2) All services must be provided in compliance with all state laws. It is the responsibility of each physician assistant to assure that he/she is in compliance with all state laws.

(3) Physician assistants are allowed to perform evaluation and management services that are commensurate with his/her training and experience. However, “consultation and critical/intensive care services” are considered to involve the practice of medicine and are not covered services for physician assistants.

(4) A patient new to the physician’s practice must be seen and personally evaluated by the employing physician before any treatment plan is initiated by the physician assistant.

(5) An established patient with a new condition must be seen and personally evaluated by the supervising physician or prior to initiation of any treatment plan for that condition.

(6) A physician assistant may not admit or release patients from a hospital independent of the supervising physician. The supervising physician must personally see and evaluate the patient prior to admission or discharge.

(7) In each situation described in paragraphs (B)(4) to (B)(6) of this rule, the medical record must document that the supervising physician was physically present, saw and evaluated the patient and discussed patient management with the physician assistant.

(C) Payment for services of a physician assistant may be made only to the physician, physician group practice, or clinic employing or contracting with the physician assistant who is providing services under physician supervision. The following provisions apply:

(1) With the exception of services defined in paragraph (C)(2) of this rule, reimbursement for services described in paragraph (B) of this rule will be the provider’s billed charge or eight-five per cent of the medicaid maximum, whichever is less. For reimbursement of physician assistant services, the physician or clinic must bill the department using the five-digit code followed by the UD modifier. Should another modifier be created, the physician may bill the modifier used nationally which signifies that a physician assistant provided the service.

(2) The following services will be considered physician services and will be paid at one hundred per cent of the medicaid maximum.

(a) Ancillary services such as collection of specimens provided by a physician assistant which are usually performed by nonphysicians;

(b) Procedures/services performed by a physician assistant and the employing physician/group also provides direct and identifiable services, including a face-to-face encounter with the patient; and

(c) For the services described in paragraphs (C)(2)(a) and (C)(2)(b) of this rule, the billing provider must bill the appropriate code unmodified.

(3) Interpretative services such as electrocardiographic or radiological interpretation are considered to be physician services and will not be reimbursed if performed by a physician assistant.

(4) Assistant-at-surgery services are not reimbursable when provided by a physician assistant.

(5) A physician, physician group practice, or clinic may not be reimbursed for initial office visits provided by a physician assistant.

(6) A physician, physician group practice, or clinic may not be reimbursed for physician assistant services in an inpatient hospital, outpatient hospital, emergency room or long-term care facility except when the physician assistant is employed by or under contract with a physician, physician group practice, or clinic.

(7) A physician, physician group practice, or clinic may be directly reimbursed for services provided in a long-term care facility as described in paragraph (F)(1)(c)(iii) or (F)(1)(c)(iv) of rule 5101:3-3-19 of the Administrative Code by a physician assistant.

(8) Separate reimbursement will not be made for visits provided on the same date of service by both a physician and a physician assistant.

(9) A physician, physician group practice, or clinic may not be reimbursed for services performed by a physician assistant which are prohibited under rule 4731-4-05 of the Administrative Code.

(D) Services performed by physician assistants are subject to the site differential payments in all places of service specified in rule 5101:3-4-02.2 of the Administrative Code if the services are performed under the supervision of a physician as described in rule 5101:3-4-02 of the Administrative Code.

HISTORY: Eff 9-1-89; 4-1-92 (Emer.); 7-1-92; 4-1-93; 11-1-01; 10-1-03

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02

R.C. 119.032 review dates: 01/07/2003 and 10/01/2008

5101:3-4-05 Teaching physician services.

(A) Definitions

(1) “Teaching physician” means a physician (other than a resident) who involves residents in the care of his/her patients.

(2) “Resident” means an individual who participates in an approved graduate medical education (GME) program. The term includes interns and fellows in approved GME programs. A medical student is never considered a resident.

(3) “Teaching setting” means any hospital-based provider setting that receives medicare or medicaid payment for the services of residents under the direct GME payment methodology.

(4) “Student” means an individual who is enrolled in an accredited medical school. A student is never considered to be an intern or a resident.

(5) “Documentation” means notes recorded in the patient’s medical records by a resident or teaching physician.

(6) “Physically present” means that the teaching physician is in the same room (or partitioned or curtained area, if the room is subdivided to accommodate multiple patients) as the patient and/or performs a face-to-face service.

(7) “Critical or key portions” means that part(s) of a service that is/are a critical or key part of the service. For the purpose of this rule, the these terms are used interchangeably. Critical or key portions means the following:

(a) For anesthesia services, it is the part of the service described in paragraph C)(2) of rule 5101:3-4-21 of the Administrative Code;

(b) For procedures, it means the parts of the service described in paragraph (E)(1)(a) to (E)(1)(h) of this rule;

(c) For evaluation and management services, it means the key portion of the service as defined in paragraph (E)(2)(b) of this rule. This definition does not apply to the evaluation and management codes listed in paragraph (E)(3)(b) of this rule; and

(d) If none of the guidelines in this paragraph apply, the teaching physician determines the critical or key portions of the service.

(8) “CPT or codes” as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

(B) General reimbursement requirements

Payment may be made directly to the teaching physician for services performed in teaching settings only under the following circumstances:

(1) The covered services are personally performed by a physician who is not a resident in a teaching setting; or

(2) The covered services are provided in a teaching setting jointly by a teaching physician and resident or by a resident in the presence of a teaching physician with certain exceptions listed in paragraph (E)(3) of this rule.

(C) A teaching physician may not be directly reimbursed for direct medical and surgical services if the teaching hospital elects to receive payment for direct medical and surgical services on a reasonable cost basis (expensed on the hospital’s cost report).

(D) Documentation

(1) For a teaching physician to be eligible for reimbursement for services, the patient’s medical record must document that the requirements for reimbursement as detailed in this rule were met. Documentation may be dictated and typed, hand written, or computer-generated.

(2) The teaching physician must meet the documentation instructions for evaluation and management (E/M) services stated in section 15016 of the medicare carrier’s manual (11/2002) including, but not limited to the following requirements:

(a) To be eligible for reimbursement for evaluation and management services, the teaching physician must personally document the following, at a minimum:

(i) A teaching physician performed the service or was physically present during the key or critical portion of the service when performed by the resident;

(ii) Documentation by the resident of the participation and presence of the teaching physician is not sufficient to establish the presence and participation of the teaching physician in the service;

(iii) The participation of the teaching physician in the management of the patient; and

(iv) The combined entries in the medical record by the teaching physician and resident together must document the medical necessity of the service.

(b) Documentation must identify:

(i) The service(s) provided;

(ii) Whether the teaching physician was present during the critical or key portions of the service provided by a resident;

(iii) The participation of the teaching physician in providing the service;

(iv) The combined entries in the medical record by the teaching physician and resident together must document the medical necessity of the service.

(v) The date; and

(vi) A legible signature or identity alone.

(c) Any contribution and participation of a student to the performance of a billable service (other than review of systems and/or past family/social history that are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirement set forth in paragraph (B) of this rule. Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the medical students documents E/M services, the teaching physician must verify and redocument the history of present illness and peform and redocument the physical exam and medical decision-making activities of the service.

(d) The following are examples of unacceptable documentation because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care:

(i) “Agree with above,” followed by legible countersignature or identity;

(ii) “Rounded, Reviewed, Agree,” followed by legible countersignature or identity;

(iii) “Discussed with resident. Agree,” followed by legible countersignature or identity;

(iv) “Seen and agree,” followed by legible countersignature or identity;

(v) “Patient seen and evaluated,” followed by legible countersignature or identity; and

(vi) A legible countersignature or identity alone.

(E) Special situations

Payment will be made for the services of a teaching physician only if the teaching physician is personally present during all critical or key portion(s) of the service.

(1) Procedures

(a) Surgery

The teaching physician must be present during all critical or key portions of the procedure and must be immediately available to provide services during the entire procedure. The teaching physician is not required to be present during the opening and closing of the surgical area. During the periods of the surgery that are not key portions, the teaching physician must be immediately available to return to the procedure. He/she must not be involved in another procedure from which he/she cannot return.

Documentation of the teaching physician’s presence during a surgery, must be documented in the medical record by the physician, resident, or operating room nurse.

In order to bill for two overlapping surgeries, the teaching physician must be present during all critical and key portions of both operations. Therefore, the critical or key portions may not take place at the same time. When all of the critical or key portions of the initial procedure have been completed, the teaching physician may begin to become involved in a second procedure. The teaching physician must personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures. The teaching physician may not bill for three or more concurrent surgical procedures. These are classified as a supervisory service to an individual patient and are not payable under the physician fee schedule.

(b) Minor procedures

For procedures that take five minutes or less, the teaching physician must be present for the entire procedure to be considered reimbursable procedures by the department.

To be considered a reimbursable endoscopy procedure, the teaching physician must be present during the entire viewing including the insertion and removal of the device.

(d) Complex or high-risk procedures

For complex or high-risk procedures such as cardiac catheterization, cardiovascular stress tests, radiologic and cardiologic supervision, and interpretation codes, the teaching physician must be physically present with the resident and must supervise the performance of the procedure or he/she must personally perform the procedure.

(e) Maternity services

In order to be considered a reimbursable service the teaching physician must be present for the delivery. The teaching physician must be physically present for the initial prenatal visit. The teaching physician must also be present during any and all prenatal visits during which there are patient complaints requiring more detailed evaluation, abnormal findings, the need for non-routine testing (e.g. non-routine ultrasonography, fetal monitoring, non stress testing, etc.), or for post date equal to or greater than forty-two week gestation.

(f) Time-based codes

For procedure codes determined on the basis of time, the teaching physician must be present for the period of time for which the claim is made. For example, a code that specifically describes a service from twenty to thirty minutes should only be billed if the teaching physician is present for twenty to thirty minutes. Time spent by the resident in the absence of the teaching physician should not be added to time spent by the resident and teaching physician with the patient or time spent by the teaching physician alone with the patient.

(g) Interpretation of diagnostic radiology and other diagnostic tests

The department will reimburse for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by or reviewed by a teaching physician.

(h) Psychiatry

Time-based psychiatry codes must meet the requirements in paragraph (E) (1) (f) of this rule. A teaching physician may not add time spent by a resident in the absence of the teaching physician to the total amount of time billed for the service. For certain psychiatric services, the presence of the teaching physician may be met by concurrent observation of the service through the use of a one-way mirror or video equipment. Audio-only equipment does not satisfy the physical presences of the teaching physician.

(i) Anesthesia

The department will reimburse for anesthesia services as outlined in 5101:3-4-21 of the Administrative Code for a teaching anesthesiologist involved in an anesthesia procedure with a resident. The teaching physician must document in the medical records that he/she was present during all critical or key portions of the procedure. The teaching physician’s physical presence during only the preoperative or post-operative visits with the patient is not sufficient to receive reimbursement.

(j) Assistants at surgery furnished at teaching hospitals The department will not reimburse for an assistant at surgery in a teaching hospital when a resident qualified to perform the service is available to assist at surgery.

(2) Evaluation and management services

(a) The “documentation guidelines for evaluation and management services” published by the American medical association in the CPT book must be the basis for the selection of the most appropriate level of evaluation and management service.

(b) The teaching physician must be physically present during the medical decision making process.

(c) The teaching physician must personally document his/her presence and participation in the service in the medical records as described in paragraph (D) of this rule.

(d) For evaluation and management services and other services based on time, the teaching physician must be physically present for the entire period of time billed. Time spent by the resident in the absence of the teaching physician is not billable. Examples of codes falling in this category include, but are not limited to, individual psychotherapy codes, critical care services, inpatient neonatal and pediatric critical care services, and evaluation and management codes in which counseling and/or coordination of care is more than fifty per cent of the encounter and time is considered the controlling factor to qualify for that specific code.

(3) Evaluation and management services furnished at primary care centers

(a) The following primary care residency programs qualify for an exception to the teaching physician policies described in paragraph (E)(2) of this rule if the programs attest in writing that they meet all of the conditions in medicare’s teaching physician policy as described in 42 C.F.R. 415.174 (10/1/2005). The primary care centers exercising the primary care exception must maintain records demonstrating that they qualify for the exception. Prior approval by the department is not required. The provider must make available a copy of this attestation to the department upon request.

(i) Family practice;

(ii) General internal medicine;

(iii) Pediatrics;

(iv) Obstetrics/gynecology; and

(v) Geriatric medicine.

(b) Payment may be made for the services of teaching physicians provided by residents without the presence of a teaching physician provided that all of the requirements listed in 42 C.F.R. 415.174 (10/1/05) are met. The following lower and mid-level evaluation and management codes may be billed under this exception when provided at a primary care center:

(i) New patient office or other outpatient codes including 99201 to 99203;

(ii) Established office or other outpatient visit codes including 99211 t 99213;

(iii) New patient preventive medicine visits codes including 99381 to 99384;

(iv) Established patient preventive medicine visits including 99391 to 99394; and

(v) Prenatal services billed with the TH modifier and codes 99201 to 99203 or 99211 to 99213 except for those listed in paragraph (E)(1)(e) of this rule.

(c) The services must be furnished in a primary care center located in a hospital outpatient department or another ambulatory care entity in which the time spent by residents in patient care duties is included in the GME payment made to a teaching hospital or hospital’s fiscal agent.

(d) When a resident is assigned to a physician’s office away from the hospital or primary care center where he/she is assigned or is making home visits, the primary care center exception does not apply and teaching physician services are not billable. In this situation, the physician’s office where the resident is assigned should bill for services provided.

(F) Modifiers

To bill for services provided by a teaching physician that meet all the provisions of this rule, the following modifiers must be used to bill for services:

(1) To bill for services performed in part by a resident under the direction of a teaching physician, use modifier “GC.”

(2) To bill for services performed by a resident without the presence of a teaching physician under the primary care exception rule described in paragraph (D)(E)(3) of this rule, use modifier “GE.”

Effective: 02/12/2006

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 10/1/87, 9/1/89, 1/1/01, 9/1/05

5101:3-4-06 Physician visits.

(A) Definitions pertaining to physician visits.

(1) “CPT” (current procedural terminology) as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

(2) A “physician visit” or an “evaluation and management (E & M) service” is a face-to-face encounter by a physician with a patient for the purpose of medically evaluating or managing the patient except for code 99211, which does not require the presence of a physician.

(3) “Outpatient visits” are visits provided to a patient in a physician’s office, a physician’s group practice, a patient’s home (excluding long-term care facilities), hospital emergency room, outpatient hospital, or clinic.

(4) “Inpatient visits” are visits provided to a hospital inpatient as defined in rule 5101:3-2-02 of the Administrative Code or consultation services provided to a patient in a long-term care facility (LTCF).

(5) The following terms are defined in the CPT book:

(a) New and established patient;

(b) Concurrent care;

(d) Levels of E & M services;

(e) Presenting problem; and

(f) Intra service, face-to-face and unit/floor time.

(B) Providers must select and bill the appropriate visit (E & M service level) code in accordance with the code definitions and the CPT instructions for selecting a level of E & M service.

Professional services associated with certain diagnostic and therapeutic procedures will be considered a part of (or bundled into) the evaluation and management service (visit) as specified in Chapter 5101:3-4 of the Administrative Code. These specified services may not be billed with an evaluation and management service code.

(1) For the reimbursement of visits provided to a patient in a physician’s office, a physician group practice, a fee-for-service clinic, or an outpatient hospital, the provider must bill the appropriate code listed in the CPT as office or other outpatient services.

(2) For reimbursement of visits provided to a patient in a rural health clinic, an outpatient health facility or a federally qualified health center, the provider must itemize the appropriate code listed under office or other outpatient services in conjunction with the appropriate encounter code for the service and provider type.

(3) After hours care.

(a) The department will compensate providers of physician services for visits provided after regularly scheduled office hours when the services are provided in an office or clinic setting.

(b) Reimbursement for after hours care is in addition to the basic services provided to the patient. For reimbursement, providers should bill the appropriate code listed in the appendix to rule 5101:3-1-60 of the Administrative Code in addition to the surgical and/or visit codes.

(D) Hospital inpatient services.

(1) For the reimbursement of visits provided to hospital inpatients, the provider must bill the appropriate code listed in the CPT under hospital inpatient services in accordance with the instructions and definitions in the CPT.

(2) Hospital care to newborns should be billed in accordance with paragraph (M) of this rule.

(E) Consultations.

(1) A consultation is a type of service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The person requesting the consultation must be a health care professional who is eligible to bill the department for physician services. When a teacher, social worker, or other non-physician (excluding an advanced practice nurse) requests a physician to evaluate a patient, these services are not reimbursable as a consultation. The physician consultant may also initiate diagnostic and/or therapeutic services.

(2) The request for a consultation from the attending physician or other appropriate source as defined in paragraph (E)(1) of this rule and the need for consultation must be documented in the patient’s medical record. The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated to the requesting physician or other appropriate source.

(3) A consultation initiated by a patient and/or family, and not requested by a physician, may not be billed using the initial or consultation codes but may be billed using the codes for regular office visits, as appropriate.

(4) If a consultant subsequently assumes responsibility for management of a portion or all of the patient’s condition(s), the appropriate evaluation and management services code for the site of service should be reported.

(5) Consultations are subject to the coverage and limitations specified in paragraph (O) of this rule.

(6) Office or other outpatient consultations.

(a) For the reimbursement of consultations provided to patients in an outpatient setting, the provider must bill one of the codes listed in the CPT under office or other outpatient consultation.

(b) When an outpatient consultation code is billed, the provider must submit the required referring physician provider information as specified in the Ohio department of job and family services professional claim billing instructions issued in accordance with rule 5101:3-1-19.3 of the Administrative Code.

(d) If an additional request for an opinion or advice regarding the same or new problem is received from the attending physician and documented in the medical record, the office and other outpatient consultation codes may be billed.

(7) Inpatient consultations.

(a) Physician consultations provided to an hospital inpatient or a resident of an LTCF (in the LTCF setting) must be billed using the codes listed in the CPT under initial inpatient consultations. Only one initial consultation code should be billed by a consultant per admission.

(b) Subsequent consultative visits requested by the patient’s attending physician or subsequent visits required to complete the initial consultation to hospital inpatients or to residents in a LTCF must be billed using the code listed in the CPT for subsequent hospital care or subsequent nursing facility care including services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem.

(c) When an initial inpatient consultation code is billed, the provider must submit the required referring physician provider information as specified in the Ohio department of job and family services professional claim billing instructions issued in accordance with rule 5101:3-1-19.3 of the Administrative Code.

(F) Emergency department services.

(1) An “emergency department” (sometimes referred to as a “hospital emergency room” or “ER”) is defined as an organized, twenty-four-hour, hospital-based facility for the provision of unscheduled episodic services to patients who seek or are in need of immediate medical attention.

(2) Whether or not the provider normally practices in the emergency department setting, evaluation and management services provided in an emergency department must be billed using:

(a) One of the codes listed in the CPT under emergency department services;

(b) The codes for critical care in accordance with paragraph (G) of this rule; and/or

(c) The appropriate surgical procedure codes in accordance with rule 5101:3-4-22 of the Administrative Code and paragraph (F)(3)(b) of this rule.

(3) When ER services are billed using the emergency department E & M codes:

(a) No distinction is made between new and established patients in the emergency department.

(b) Only surgical procedures that are identified with an asterisk in appendix DD to rule 5101:3-1-60 of the Administrative Code may be billed in conjunction with an emergency department services code.

(4) Surgical codes may be billed in lieu of an evaluation and management service (e.g., code 12006).

(G) Critical care services

(1) Critical care includes the care of critically ill patients as defined in the physician’s CPT.

(2) Management of a critically ill patient may be billed using the codes listed in the CPT under critical care services.

(3) Certain services are included in the critical care codes and are not separately reimbursable when the critical care codes are billed. These services are specified in the critical care services section of the CPT.

(4) Critical care begins at the time the physician arrives to begin evaluation and treatment and ends when the physician’s presence is no longer required as defined in the CPT.

(a) The critical care codes may be billed to report the total duration of time, to a maximum of two hours, spent by a physician providing constant attention to a critically ill patient even if the time spent by the physician is not continuous on that day.

(b) Code 99291 must be billed to report the first thirty to seventy-four minutes of critical care provided on a given day and code 99292 must be billed to report each additional thirty minutes as defined by the CPT.

(c) If the total duration of time spent with the patient is less than thirty minutes, the provider must bill the appropriate hospital, emergency department, or other visit code.

(d) Inpatient critical care provided to infants twenty-nine days up through twenty-four months of age must be reported with the inpatient pediatric critical care codes 99293 and 99294. These codes must be billed only once per day per physician per patient. Inpatient critical care services provided to neonates twenty-eight days or less should be billed with the inpatient neonatal critical care codes 99295 and 99296 as long as the neonate qualifies for critical services during the hospital stay. Inpatient care for a critically ill or critically injured child older than two years when admitted to an intensive care unit must be billed with hourly critical care codes 99291 and 99292.

(e) Inpatient critical care provided to neonates who are defined as infants twenty-eight days of age or less at the time of admission to a critical care unit, are reported with the neonate critical care codes listed in the CPT book.

(i) Once the neonate is no longer considered to be critically ill, the continuing intensive (non-critical) low birth weight service codes specified in CPT must be used to bill for services subsequent to the day of admission provided by a physician directing the intensive care of the low birth weight or very low birth weight infant who no longer meets the definition of critically ill for those with present body weight of less than five thousand grams, the appropriate E & M code must be billed. When the present body weight of the infant exceeds five thousand grams bill the appropriate code under subsequent hospital care.

All codes delineated under continuing intensive care services represent subsequent days of care and are reimbursable only once per calendar day per patient. These are considered global codes with the same services bundled as outlined in CPT under “inpatient neonatal and pediatric critical care services.”

(ii) Inpatient neonatal and pediatric critical care codes are global twenty-four hour codes and must be billed on a per day basis. Services for a patient who is not critically ill, but happens to be in a critical care unit must be reported using other appropriate evaluation and management codes.

(iii) Certain procedures are included in the global pediatric and neonate codes and must not be billed separately. These procedures are specified in the neonatal and pediatric critical care section of the CPT.

(iv) The initial neonatal inpatient critical care code 99295 may be billed as appropriate in addition to 99436 or 99440 when the physician is present for the delivery ( 99436) and newborn resuscitation (99440) is required. Other procedures performed as part of the resuscitation such as endotracheal intubation (31500) should be billed separately if they are performed as a necessary component of the resuscitation and not as a convenience before admission to the neonatal intensive care unit.

(v) Critical care services provided in the outpatient setting, e.g. emergency department or office for neonates and pediatric patients up through twenty-four months of age, should be billed with the critical care codes 99291 to 99292.

(vi) If the same physician provides critical care services for a neonatal or pediatric patient in both the outpatient and inpatient settings on the same day, bill only the appropriate neonatal or pediatric critical care code (99293 to 99296) for all critical care services provided that day.

(5) Surgical procedures may be billed in conjunction with a critical care code only if the procedure is identified by an asterisk in appendix DD to rule 5101:3-1-60 of the Administrative Code and it is not one of the procedures itemized in paragraph (G)(3) of this rule.

(H) Other evaluation and management service- initial intensive hospital care for the management of a neonate, twenty-eight days of age or less.

(1) Initial hospital care for the evaluation and management of a neonate twenty-eight days of age or less requires intensive observation, frequent interventions, and other intensive care services.

(2) Initial hospital care for the evaluation and management of neonates twenty-eight days or less requiring intensive observation, frequent interventions, and other intensive care services are reported under the other evaluation and management services code listed in the CPT book.

(3) Initial hospital care for the evaluation and management of neonates twenty-eight days or less requiring intensive observation, frequent interventions, and other intensive care services is a global twenty-four hour code and must be billed once per admission and on the first day of care.

(4) For the initiation of inpatient hospital care of a normal newborn, or a critically ill neonate, or for initial inpatient hospital care of a neonate not requring intensive observation, frequent interventions, and other intensive care services, bill the codes specified in the CPT.

(5) CPT code 99477 will not be reimbursed when billed on the same date of service with CPT codes 99295 or 99221 through 99223.

(6) Subsequent inpatient hospital intensive care services provided to neonates are reported following CPT guidelines under the subsequent inpatient neonatal critical care code.

(I) Nursing facility services.

(1) A physician may not be directly reimbursed for a LTCF visit if the service provided is the periodic review of a resident’s medical record, plan of care, and/or habilitation plan and a face-to-face encounter with the patient is not provided.

(2) A physician may be reimbursed for a LTCF visit as detailed in rule 5101:3-3-19 of the Administrative Code only if the physician personally performed a physical examination on a LTCF resident and documented the visit in the resident’s medical record. The guidelines listed in the CPT for LTCF codes must be followed.

(3) A physician may also be reimbursed for a LTCF visit provided by a physician assistant (PA) or nurse practitioner under the physician’s employment in accordance with rule 5101:3-3-19 of the Administrative Code.

(4) The department will no longer differentiate payment for LTCF visits based on the number of residents examined.

(a) For the reimbursement of physician visits provided by a physician or nurse practitioner in a LTCF, the provider must bill the appropriate code listed in the CPT under nursing facility services (e.g., 99307). Services provided by a nurse practitioner must be modified by the appropriate modifier as specified in rule 5101:3-8-27 of the Administrative Code.

(b) For the reimbursement of a visit provided by a PA to a patient in a LTCF, the employing physician(s) must bill the appropriate code listed in the CPT under nursing facility services modified as described in the physician assistant rule 5101:3-4-03 of the Administrative Code.

(5) All codes listed under “other nursing facility services” in the CPT are not reimbursable on the same day of service as the nursing facility service codes.

(6) Physician visits provided in the LTCF are subject to the visit limitations defined in paragraph (O) of this rule.

(J) Domiciliary, rest home (e.g., boarding home) or custodial care services.

For visits provided to patients in a facility that provides room, board and other personal assistance services on a long-term basis (e.g., domiciliary, rest home, boarding home), the provider must bill using the visit codes listed in the CPT under domiciliary, rest home, or custodial care services.

(K) Domiciliary, rest home, or home care plan oversight services.

Codes listed in this section of the CPT are not covered by the department. Reimbursement is bundled into the payment of another service.

(L) Home services.

For visits provided to a patient confined to his or her private residence (“homebound patient”), the provider must bill the appropriate code listed in the CPT under home services.

(M) Newborn care.

(1) Predelivery visit to a pediatrician or other primary care physician.

(a) To encourage families to obtain early and continuous well-child and primary sick care for their newborn, the department will cover a predelivery visit to a pediatrician or other primary care provider of physician services. The purpose of this service is to give the mother (or family) the opportunity to select, and establish a patient relationship with, a physician for the care of her (their) newborn.

(b) For reimbursement of this service, the provider must bill the appropriate evaluation and management code.

(2) The newborn care codes should be used for the following:

(a) The initial history and examination of a normal newborn delivered in a hospital or birthing room setting;

(b) Subsequent hospital care provided to a normal newborn on a per day basis;

(c) Initial history and examination of a normal newborn delivered in a setting other than a hospital or birthing room setting; and

(d) Initial history and examination of a high-risk newborn in accordance with paragraph (M)(2) of this rule.

(3) Pediatrician delivery services for high risk newborns and newborn resuscitation services.

A “high-risk newborn” shall be defined as an infant who is delivered by Cesarean or determined, prior to (or after) the immediate delivery, to be at-risk of prematurity or a poor prognosis.

(a) Services of a pediatrician, when requested by the delivering physician, in attendance at a delivery and for the initial stabilization of a high risk newborn or a Cesarean section may be billed using code 99436. This code cannot be used when the billing physician does any of the following while in attendance at the delivery.

(i) Provide care or services to other patients;

(ii) Perform a procedure subject to a surgical package; or

(iii) Proctor another physician.

(b) The newborn resuscitation code may be billed only if resuscitation services are actually provided to the newborn. This service involves the provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.

(c) The newborn resuscitation code and the physician attendance codes may be billed with the codes for newborn care, neonatal intensive care and hospitals visits. However, the newborn resuscitation code (99440) and the physician attendance code (99436) are not to be billed together.

(4) Subsequent care of a sick newborn in an inpatient hospital setting must be billed using the subsequent hospital visit codes or the newborn critical care codes in the CPT.

(5) Routine well baby care provided in an outpatient setting should be billed in accordance with Chapter 5101:3-14 of the Administrative Code.

(6) Subsequent care of a sick newborn in an outpatient setting should be billed using the codes for outpatient E & M services.

(N) Initial observation care and observation or inpatient care services (including admission and discharge services).

(1) The department will recognize initial observation care for patients who are treated in an outpatient or emergency room setting and the patient’s condition does not require an inpatient hospital admission but does require a period of medical observation and/or treatment that is greater than or equal to four hours and less then twenty-two hours of care. To bill for initial observation care the provider must bill the appropriate code for initial observation care.

(2) If the patient was in observation care status for a minimum of eight hours, the physician must bill the observation care codes. Otherwise, the physician must bill the admission codes (99218 to 99220).

(3) If patient care results in a hospital admission and the physician who provided the initial observation care continues to be the patient’s attending physician after the admission, the physician must bill the inpatient hospital E & M codes in lieu of the initial observation codes.

(4) If patient care results in a hospital admission on the same date that observation care was initiated and the physician who provided the observation care does not continue to be the patient’s attending physician after the admission (care is transferred to another physician), the physician who provided the observation care may bill for the initial observation services and the new attending physician may bill an inpatient hospital EM code.

(5) If observation care extends over to a second date of service, the code for observation care discharge day management may be billed when the patient is discharged as specified in the “initial observation care” section of CPT. However, when the initial observation care is less than eight hours, the department will not reimburse for the code for discharge day management even if the care extends over to a second day of service.

(6) Observation services provided to a patient who is discharged on the same date must be billed using only the codes specified in the “observation or inpatient care services” section of CPT.

(7) Observation codes may not be utilized for post-operative recovery if the service is considered a global surgical procedure code.

(O) Limitations on physician visits.

(1) Outpatient visits.

(a) Reimbursement will be made for all physician visits provided to a recipient in an outpatient or an LTCF setting during a calendar year up to a total of twenty-four visits.

(b) Physician visits in excess of twenty-four will be paid as the services are billed to the department but will be subject to post-payment review by the department.

(c) The total number of physician visits accrued by a recipient during a calendar year will be calculated by the department and shall be referred to as the year-to-date visit total.

(d) The following codes will be counted as a physician visit and added to the recipient’s year-to-date visit total, unless the codes are billed on an institutional claim form or institutional electronic transaction or the codes are billed with one of the diagnoses listed in paragraph (O)(1)(d)(vi) of this rule:

(i) Codes 99050 to 99051;

(ii) Codes 99304 to 99310, 99315 to 99318, 99324 to 99328, and 99334 to 99337;

(iii) Codes 99241 to 99255 when the service is provided in a setting other than in patient hospital;

(iv) Codes 99201 to 99215;

(v) Codes 99281 to 99285; and

(vi) Codes 99341 to 99350.

The year-to-date visit total will be an accumulative total of visits provided by all providers of physician services, including but not limited to all physicians, clinics, and podiatrists.

(e) The following physician visits shall be exempted from counting towards the recipient’s year-to-date visit total:

(i) All antepartum and postpartum visits as detailed in rule 5101:3-4-08 of the Administrative Code and all pregnancy related services as detailed in rule 5101:3-4-10 of the Administrative Code;

(ii) All well-child or EPSDT (healthchek) visits as detailed in rule 5101:3-14-04 of the Administrative Code;

(iii) All inpatient hospital and critical care visits as defined in this rule;

(iv) Allergen immunotherapy services not billed in conjunction with a code listed in paragraph (O)(1)(d) of this rule;

(v) All other visits or services billed under a code not listed in paragraph (O)(1)(d) of this rule;

(vi) All visits provided for the following diagnoses:

(a) End-stage renal disease;

(b) Chemotherapy or radiation therapy for malignancy;

(c) End-stage lung disease;

(d) Unstable diabetes or diabetes with complications;

(e) Uncontrolled hypertension or hypertension with complications;

(f) Neoplasms and leukemia;

(g) Organ transplants;

(h) Hereditary anemias;

(i) Hemophilia or other congenital disorders of clotting factors;

(j) Acquired hemolytic anemias;

(k) Aplastic anemias;

(l) Deficiency of humoral immunity;

(m) Deficiency of cell-mediated immunity;

(n) Combined immunity deficiency;

(o) Cystic fibrosis;

(p) Malabsorption;

(q) Failure to thrive;

(r) Infant prematurity;

(s) Respiratory distress syndrome and other respiratory conditions of the fetus and newborn; and

(t) Terminal stage of any life-threatening illness.

(vii) For a visit not to count towards the year-to-date visit total, the provider must bill either a code indicating an exempted service was provided or the visit code with the primary or secondary diagnosis code indicating the patient has one of the exempted conditions.

(f) When the department has paid for more than twenty-four unexempted physician visits for a recipient during a calendar year, information from paid claims history will be reviewed by the department to determine whether the recipient should be referred to a primary care alternative and treatment (PACT) program or given the option to voluntarily enroll in a managed care plan (MCP), if the recipient is eligible to enroll.

(i) In addition, the department or its contractual designees may:

(a) Review the medical records of any recipient exceeding twenty-four visits during a calendar year to determine whether the services were medically necessary and appropriate for the recipient’s illness, symptoms or injury; and/or

(b) Conduct an in-depth review of any provider and the provider’s medical records if the provider shows an unusual pattern of providing greater than twenty-four visits to medicaid recipients.

(ii) If the department determines that the physician visits were not medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, the payment for the visits may be recovered from the provider by the department.

(2) Inpatient hospital visits.

(a) Inpatient hospital visits, excluding critical care visits, shall be limited to one visit per day per patient per provider.

(b) Critical care visits must be billed in accordance with paragraph (G) of this rule.

(3) Visits performed in conjunction with surgical procedures.

(a) Minimum follow-up period.

(i) The minimum surgical follow-up period is defined for each surgical procedure under follow-up days in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(ii) The day of surgery is included in the minimum follow-up period, except when the procedure is identified by an asterisk in appendix DD to rule 5101:3-1-60 of the Administrative Code.

In the 2004 CPT, the starred procedure designation was removed from surgical codes. Therefore the department has removed the asterisk from most surgical procedures. The department will continue the asterisk designation in appendix DD to rule 5101:3-1-60 of the Administrative Code for a limited number of procedures such as venipuncture procedures.

(a) For those procedures where the asterisk was removed, for claims received on and after January 1, 2004 a follow-up visit will no longer be allowed;

(b) For the venipuncture procedures, which are asterisked in rule 5101:3-1-60 of the Administrative Code, a visit on the same day as surgery will be allowed if the provisions in paragraph (O)(3)(c) of this rule are met.

(iii) When more than one procedure is performed on the same day, the follow-up period will be equal to the follow-up period of the surgical procedure with the most follow-up days.

(iv) When another surgical procedure is performed during the follow-up period of a previously performed surgery, the follow-up period will be equal to the follow-up period of the most current surgical procedure or the remaining days left of the follow-up period for the original (or first) surgical procedure, whichever is longer.

(b) Preoperative visits.

(i) Preoperative examinations to evaluate the patient and to determine the necessity of surgery are separately reimbursed when the examination is not performed on the day of surgery.

(ii) All preoperative visits performed by the surgeon after the decision to have surgery is made are included in the global surgical package.

A provider may be reimbursed for a visit on the same day as surgery, only if the procedure is identified by an asterisk in appendix DD to rule 5101:3-1-60 of the Administrative Code and it is customary for the physician to charge a visit for all patients.

(d) Postoperative visits.

(i) Routine postoperative visits.

Reimbursement for all routine postoperative care is included in the physician’s reimbursement for surgical procedures.

(a) The physician may not be separately reimbursed for routine postoperative visits provided during the minimum follow-up period.

(b) The physician may not be separately reimbursed for routine postoperative visits, even if the visits occurred after the minimum follow-up period.

(ii) Nonroutine postoperative visits.

(a) A physician may be reimbursed for visits provided during the minimum surgical follow-up period only if the visit was provided after the day of surgery and the visit was provided for the diagnosis and/or treatment of a symptom illness or condition that was unrelated to the surgical procedure (previously) performed.

(b) Visits provided during the minimum surgical follow-up period must be billed as described in this paragraph.

(i) When the visits described in paragraph (O)(3)(d)(ii)(a) of this rule are provided by a physician who did not perform the surgical procedure, the physician may be reimbursed by billing the code for the visit.

(ii) When the visits described in paragraph (O)(3)(d)(ii)(a) of this rule are provided by the physician who also performed the surgical procedure, the physician may be reimbursed by billing the code for the visit modified by the modifier 24 (unrelated evaluation and management service by the same physician during a postoperative period).

(e) Visits performed in conjunction with surgical procedures are subject to all other visit limitations defined in this rule.

Effective: 03/30/2008

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 7/1/80, 6/3/83, 10/1/83 (Emer), 12/29/83, 1/1/86, 5/9/86, 10/1/87, 6/16/88, 1/13/89 (Emer), 4/13/89, 9/1/89, 5/1/90, 2/17/91, 5/25/91, 4/1/92 (Emer), 7/1/92, 12/31/92 (Emer), 4/1/93, 12/30/93 (Emer) 3/31/94, 12/30/94 (Emer), 3/30/95, 12/29/95 (Emer), 3/21/96, 7/1/96, 12/31/97 (Emer), 3/19/98, 12/31/98 (Emer), 3/31/99, 3/20/00, 3/20/01, 7/1/03, 1/2/04 (Emer), 4/1/04, 12/30/04 (Emer), 3/20/05, 9/1/05, 12/30/05 (Emer), 3/27/06, 12/29/06 (Emer), 3/29/07, 12/31/07 (Emer)

5101:3-4-06.1 Physician attendance during patient transport.

(A) The following paragraphs apply to patient transports for both pediatric patients twenty-four months or less in age and patients older than twenty-four months:

(1) Face-to-face time begins when the physician assumes responsibility of the patient at the referring facility/hospital and ends when the receiving facility/hospital accepts responsibility for the patient’s care. Only the time the physician spends in direct face-to-face contact with the patient during the transport should be billed.

(2) Services provided by other members of the transport team must not be billed by the physician but must be billed by the transportation company, e.g. ambulance provider.

(3) Routine monitoring evaluations, e.g. heart or respiratory rate, blood pressure, pulse oximetry, and the initiation of mechanical ventilation are included in the face-to-face time reported in the patient transport codes and will not be paid separately.

(4) The direction of emergency care to transporting staff by a physician located in a hospital/facility by two-way communication is not considered direct face-to-face care and must not be reported using the patient transport codes.

(5) The patient transport services are covered by the department only if the service is personally provided by a physician.

(6) The codes for the initial care of the critically ill or critically injured patient should be billed only once on a given date.

(7) “CPT” as referenced in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

(B) The following paragraphs apply to patient transports of pediatric patients:

(1) The procedure codes 99289 and 99290 for pediatric patient transport found in rule 5101:3-1-60 of the Administrative Code are used to report the physical attendance and direct face-to-face time spent by a physician during the inter-agency transport of a critically injured or critically ill pediatric patient twenty-four months of age or less.

(2) These procedure codes are time-based. Pediatric patient transport services involving less than thirty minutes of face-to-face physician care should not be reported using the patient transport codes.

(3) Certain procedures are included in the global critically ill or critically injured pediatric patient transport codes and should not be billed separately. These procedures are specified in the pediatric critical care patient transport section of the CPT.

(1) Critical care codes 99291 and 99292 should be billed when a physician is in attendance during the transport of a critically ill or critically injured patient over twenty-four months of age to and from a facility/hospital.

(2) When billing the critical care codes specified in paragraph (C) (1) of this rule for a patient transport, the provider must modify the code by “UB” to indicate that the code is being billed for a patient transport for a critically ill or injured patient over twenty-four months of age. When billing 99292 for a critically ill patient who has had a physician in attendance during the patient transport and then received critical care in the hospital, bill 99292 UB for the time the physician spent in attendance during the transport. Bill code 99292 unmodified for the time spent providing critical care in the hospital.

(3) The policies and specified in paragraph (G) of rule 5101:3-4-06 of the Administrative Code apply to patient transports billed with critical care codes, except for the maximum of two hours reimbursable for these codes.

HISTORY: Eff 12-31-01 (Emer.); 3-29-02; 7-1-03

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 51110.1, 5111.02

Replaces: 5101:3-4-06.1

R.C. 119.032 review dates: 07/01/2008

5101:3-4-07 Family planning services.

(A) Family planning is the means of enabling individuals of childbearing age, including minors who can be considered to be sexually active, to determine freely the number and spacing of their children.

(B) Covered family planning services include medical, consultative, and educational services related to:

(1) Temporary contraceptive management;

(2) Permanent contraceptive management (sterilization);

(3) Physical and emotional reproductive health of the patient;

(4) Genetic counseling and diagnostic testing;

(5) Pregnancy determination.

(1) Infertility services;

(2) Hysterectomies performed for sterilization purposes;

(3) Abortions performed to terminate an unwanted pregnancy.

(D) Family planning visits.

(1) A “family planning visit” is any visit performed for the purpose of providing a family planning service. The visit may be performed either by a physician and/or a health professional or social service professional qualified under the Revised Code. The visit may or may not include a physical examination.

(2) For the reimbursement of family planning visits, providers may bill one of the following codes

99211 To indicate a minimal family planning visit not necessarily requiring the presence of a physician. Services include, but are not limited to, obtaining weight, blood pressure, overseeing laboratory orders, and filling, refilling, or renewing a prescription for contraceptive pharmaceuticals or supplies upon the orders of a physician when a physical examination is not required.

H1011 to indicate a non-medical family planning education visit conducted by a health professional other than a physician, such as a registered nurse or a trained medical/psychiatric or social worker, regarding medical history, medical complaints, general reproductive health, genetic problems, and contraceptive methods.

S0610 (new patient) or S0612 (established patient) to indicate an annual gynecological examination not performed by a physician in which a physical examination including, at a minimum, a review of the medical history, pelvic examination, height, weight, and blood pressure, is performed in conjunction with family planning services by a physician assistant or registered nurse as allowed under the Revised Code. The visit includes, when appropriate, all or a combination of the following services: breast examination, checking an IUD, contraceptive, genetic counseling, collection of a pap smear, vaginal smears, or cultures. Bill the appropriate modifier specified in paragraph (D) (3) (c) of this rule if the services are provided by a non-physician. Services billed by a nurse practitioner or nurse-midwife will be reimbursed at the lesser of billed charges or eighty-five per cent of the medicaid maximum.

S0610 (new patient) or S0612 (established patient) to indicate a gynecological examination performed by a physician in which a physical examination including, at a minimum, a review of the medical history, pelvic examination, height, weight and blood pressure, is performed in conjunction with family planning services. The visit also includes, when appropriate, all or a combination of the following services: breast examination, collection of a pap smear, collection of vaginal smears or cultures, evaluation and interpretation of laboratory procedures, checking an IUD, contraceptive counseling, genetic counseling, and the prescription of contraceptive pharmaceuticals and supplies.

(3) For reimbursement of family planning services, the following provisions must be followed when a claim is submitted:

(a) Providers must bill a family planning diagnosis code:

(i) V25 indicating an encounter for contraceptive management or

(ii) V26 indicating an encounter for procreative management.

(b) For all family planning services, bill the “FP” modifier to indicate that services are provided as part of family planning.

(c) Services provided by a nurse practitioner or a nurse mid-wife must be billed with modifiers to indicate the provider that rendered the service:

(i) Use the “SA” modifier to indicate that a nurse practitioner rendered the service in collaboration with a physician; or

(ii) Use the “SB” modifier to indicate that a nurse midwife provided the service.

(E) Laboratory services covered as family planning.

(1) The following laboratory procedures are covered as family planning services when performed for contraceptive or procreative (other than infertility) management:

(a) Hematocrit and/or hemoglobin;

(b) Urinalysis;

(d) Gonorrhea smear and/or culture;

(e) VDRL or RPR for syphilis testing;

(f) Rubella testing; and

(g) Sexually transmitted infection testing; cultures.

(2) The following laboratory procedures are covered as family planning services when the patient is in a high-risk category for oral contraceptives (e.g., by the family’s or individual’s medical history):

(a) Fasting blood glucose;

(b) Two-hour postprandial blood glucose for patients who are known diabetics;

(d) Liver function tests. There must be documentation in the medical records supporting the patient’s high-risk status.

(3) The following laboratory procedures for the screening of sexually transmitted infections, including gonorrhea or syphilis, are covered family planning services when the physician believes that the patient is at high-risk of contracting such diseases or the patient has symptoms indicative of such infections:

(a) Chlamydia;

(b) Condyloma;

(d) Herpes;

(e) Trichomoniasis;

(f) Genital moniliasis;

(g) HIV.

The medical indications must be noted in the patient’s medical records.

(4) The following laboratory procedures are covered as family planning services when performed for the screening and determination of genetic anomalies and/or hereditary metabolic disorders:

(a) Chromosomal studies;

(b) Sickle cell tests or tests to detect other abnormal hemoglobin syndromes;

(5) Laboratory procedures to confirm pregnancy are covered as family planning services. Routine antepartum laboratory testing is covered as obstetrical services and not family planning.

(F) Medical/surgical procedures related to family planning.

The following medical or surgical procedures are covered as family planning services:

(1) Diaphragm fitting with instructions;

(2) Insertion of intrauterine device (IUD);

(3) Removal of intrauterine device; and

(4) Contraceptive subdermal implant removal.

(G) Pharmaceutical supplies and devices.

(1) Pharmaceutical supplies and devices to prevent conception through chemical, mechanical, or other means including natural childbirth are covered as family planning services and are specified in the appendix to 5101:3-1-60 of the Administrative Code, or as a family planning supply or device dispensed for take home use and billed in accordance with Chapter 5101:3-9 of the Administrative Code.

(2) Reimbursement for family planning pharmaceutical or medical supplies and devices.

(a) A physician or other eligible provider with prescriptive authority under Ohio law may be reimbursed for all covered family planning pharmaceutical or medical supplies and devices actually dispensed.

(b) For reimbursement of a family planning pharmaceutical dispensed for take-home use, the provider must have a category of service “30” and bill for the services in accordance with the provisions set forth in Chapter 5101:3-9 of the Administrative Code.

(c) For reimbursement of a family planning medical supply dispensed for take-home use, the provider must have a category of service “32” and bill for the services on the ODJFS invoice for DME services in accordance with Chapter 5101:3-10 of the Administrative Code.

(d) For reimbursement of IUD’s inserted or injections administered during a visit, the provider may bill for the services on the invoice used to submit physician’s services (e.g., visits, etc.).

(H) Sterilization services.

The following permanent sterilization procedures are covered as family planning services (provided they meet the requirements for sterilization as specified in rule 5101:3-21-01 of the Administrative Code):

(1) Endoscopic and other bilateral destruction or occlusion of fallopian tubes, any method;

(2) Bilateral partial salpingectomy (BPS) performed for sterilization, any method. Salpingectomies, salpingo-oophorectomies, oophorectomies, or other surgical procedures which result in sterilization, but are performed only for medically necessary reasons, are not considered family planning services;

(3) Vasectomy;

(4) Ligation of vas deferens, any method;

(5) Ligation of spermatic cord, any method.

(I) Pregnancy determination.

(1) Pregnancy testing and the initial pelvic examination to confirm pregnancy are covered as family planning services. Obstetrical services are not considered family planning services.

(2) If a pregnancy is confirmed by testing and examination, a “Prenatal Risk Assessment” form must be completed and submitted to the department as detailed under rule 5101:3-4-08 of the Administrative Code.

Effective: 03/27/2006

R.C. 119.032 review dates: 10/01/2008

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 9/1/89, 5/25/91, 4/1/92 (Emer), 7/1/92, 12/31/92 (Emer), 4/1/93, 5/2/94 (Emer), 7/1/94, 3/20/95, 1/1/01, 10/1/03, 12/30/05 (Emer)

5101:3-4-08 Covered obstetrical services.

(A) Providers of obstetrical services must bill each antepartum visit, separately. The department does not recognize the codes for “global obstetrical care” which bundle these services under a single procedure code. The department does recognize the code for delivery and postpartum services which may be billed using a single procedure code when the services are provided by the same provider.

(B) The following obstetrical services are covered as detailed below:

(1) Prenatal risk assessment;

(2) All antepartum care including pregnancy related services;

(3) Delivery; and

(4) Postpartum care.

(1) The “Prenatal Risk Assessment (PRA)” form, JFS 03535, is a checklist of medical and social factors which is used as a guideline to determine when a patient is at risk of a preterm birth or poor pregnancy outcome.

(2) The PRA form must be completed on each obstetrical patient during the initial antepartum visit in order to bill for the prenatal at-risk assessment code. A copy of the PRA form should be placed in the patient’s record to serve as documentation that the service was provided.

(3) Providers must submit a copy of the PRA form to the patient’s residential county department of job and family services since the county staff can assist patients obtaining needed services.

(4) When significant risk factors that were not noted on the original PRA form are identified during the course of the pregnancy, providers are encouraged to complete another risk assessment form and to send a copy to the county department of job and family services.

(5) Providers may receive reimbursement for completing the PRA form by billing the code for prenatal risk assessment specified in rule 5101:3-4-10 of the Administrative Code.

(D) Antepartum care

(1) Antepartum visits

(a) The antepartum visit is inclusive of:

(i) Instruction, education and counseling on a variety of topics related to pregnancy, nutrition, baby-care and family;

(ii) Routine urinalysis screening tests (dipstick) to detect the presence of sugar or protein;

(iii) A physical examination which includes recording of weight, blood pressure, and fetal heart tones or similar routine services;

(iv) Coordination of the patient’s medical care including at a minimum a planned hospital delivery, arrangements for medical care and/or consultation (by telephone) in case of an emergency, and referrals to appropriate medical services (i.e., ultrasounds, etc.).

(b) Medical care coordination, education and counseling services provided as part of the antepartum visit should be consistent with those services generally required for all obstetrical patients. When the care coordination and/or counseling and educational services provided to an individual are more extensive than the services routinely provided to obstetrical patients, a provider may be compensated for these services by billing the pregnancy related services detailed in rule 5101:3-4-10 of the Administrative Code.

(c) Antepartum visits must be billed to the department on a per-visit basis using the evaluation and management (office visit) code appropriate for the type of visit documented in the patient’s record. When the antepartum visit is billed, specify a diagnosis to signify pregnancy such as V22 for supervision of normal pregnancy, V23 for supervision of a high-risk pregnancy, or V28 for antenatal screening. Bill the code modified by the “TH” modifier to signify “obstetrical services, prenatal or post-partum”.

(2) Additional services

(a) In addition to the antepartum visit, reimbursement is available for the following services provided during the antepartum and postpartum periods:

(i) Pregnancy related services which are described in rule 5101:3-4-10 of the Administrative Code.

(ii) All obstetrical-related radiology and laboratory procedures (with the exception of urinalysis screening tests) actually performed in the physician’s office;

(iii) All obstetrical diagnostic procedures identified in standard code sets; and

(iv) All covered medical services provided in addition to the antepartum visit.

(b) The services listed in paragraph (D)(2)(a) of this rule may be provided independently on any date of service, or they may occur sequentially on the same date as the antepartum visit or any other covered service.

(E) Delivery and postpartum care.

(1) “Delivery services” include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without forceps and/or episiotomy), or Cesarean section delivery.

(2) “Postpartum care” includes hospital and office visits for routine, uncomplicated care following a vaginal or Cesarean section delivery.

(3) Under paragraph (E) of this rule, “same provider” means the rendering provider or any member of the same group practice.

(4) The following codes should be billed:

(a) For delivery and postpartum services provided to patients for which a vaginal or Cesarean delivery after a previous Cesarean delivery (VBAC) was not attempted.

59409 For a vaginal delivery when outpatient postpartum care is provided by another provider or provider group.

59410 For a vaginal delivery when outpatient postpartum care is provided by the same provider or provider group.

59514 For a Cesarean section when outpatient postpartum care is provided by another provider or provider group.

59515 For a Cesarean section when outpatient postpartum care is provided by the same provider or provider group.

(b) For delivery and postpartum services provided on or after January 1, 1996 to patients for which a VBAC was attempted.

59612 For a vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) when outpatient postpartum care is provided by another provider or provider group.

59614 For a vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) when outpatient postpartum care is provided by the same provider or provider group.

59620 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery when outpatient postpartum care is provided by another provider or provider group.

59622 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery when outpatient postpartum care is provided by the same provider or provider group.

59430 For postpartum care only.

(5) For the reimbursement of codes 59410, 59430, 59515, 59614 or 59622, the provider must, at a minimum, render an evaluation and management service four to six weeks post-delivery.

(6) Under the medicaid program, the provision of postpartum care rendered prior to discharge from the inpatient hospital, outpatient hospital or birthing center (i.e. the delivering institution) is considered incidental to the delivery services and/or postpartum service and should not be a factor when selecting the delivery only codes or the delivery codes bundled with the postpartum care services.

(a) For the reimbursement of the delivery only codes the provider or provider group must render, at a minimum, the delivery service;

(b) For reimbursement of the delivery and postpartum care codes, the provider or provider group practice must render, at a minimum, bot the delivery and at least one evaluation and management service four to six weeks post-delivery;

(c) For the reimbursement of the postpartum care only code, the provider or provider group practice must render, at a minimum, at least one evaluation and management service four to six weeks post surgery.

(7) Additional reimbursement will not be recognized for the complexity of the delivery, for multiple births, or for two physicians performing the same vaginal delivery.

(8) Reimbursement is available for inpatient and outpatient evaluation and management services provided for post-delivery complications or services unrelated to the delivery in accordance with paragraph (M)(3) of rule 5101:3-4-06 of the Administrative Code.

(9) Services of an assistant-at-surgery during a Cesarean delivery are covered in accordance with paragraph (G) of rule 5101:3-4-22 of the Administrative Code.

(10) Services of a pediatrician in attendance at a delivery of a high risk newborn or a Cesarean section are covered in accordance with rule 5101:3-4-06 of the Administrative Code.

(11) All pregnancy related services are covered services during the postpartum period with the exception of high-risk patient monitoring and the predelivery visit.

(F) Transportation services for pregnant women to medicaid covered services will be provided by the patient’s residential county department of job and family services, if it is requested by the provider, the recipient or other person acting on the recipient’s behalf.

HISTORY: Eff 4-7-77; 12-21-77; 12-30-77; 1-8-79; 2-1-80; 4-1-88; 9-1-89; 5-1-90; 2-14-92 (Emer.); 5-14-92; 12-30-93 (Emer.); 3-31-94; 3-30-95; 12-29-95 (Emer.); 3-21-96; 5-9-96; 7-1-03

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.02

R.C. 119.032 review dates: 10/08/2002 and 07/01/2008

5101:3-4-08.1 Payment for prenatal visits.

(A) Paragraph (D)(1)(c) of rule 5101:3-4-08 of the Administrative Code specifies that providers billing for an antepartum/prenatal visit must bill the code for an evaluation and management office visit to receive reimbursement for a prenatal visit. Providers must choose the office visit code appropriate for the visit documented in the patient’s record and modify the code by the “TH” modifier to signify that the visit was for prenatal services.

(B) When the “TH” modifier is billed with an office visit code, the following reimbursement will be made effective for dates of service on and after July 1, 2008:

Office Visit Type Codes Medicaid Maximum

new patient 99201 to and including 99202 $49.85

new patient 99203 see rule 5101:3-1-60 of the Administrative Code

new patient 99204 see rule 5101:3-1-60 of the Administrative Code

new patient 99205 see rule 5101:3-1-60 of the Administrative Code

established patient 99211 $19.73

established patient 99212 to and including 99213 $49.85

established patient 99214 see rule 5101:3-1-60 of the Administrative Code

established patient 99215 see rule 5101:3-1-60 of the Administrative Code

(C) Providers must follow the instructions for selecting the level of evaluation and management service specified in the “CPT” manual. “CPT” as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

Effective: 07/01/2008

R.C. 119.032 review dates: 09/25/2007 and 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 10/1/03

5101:3-4-09 Office incentive program.

(A) In order to encourage physicians and clinics to perform certain services and procedures in office or clinic settings instead of hospital settings, the department will make a payment of fifteen dollars, twenty-five dollars, or fifty dollars in addition to the normal payment made for the services or procedures listed in appendix A to this rule. The purpose of the additional payment is to compensate physicians for the additional cost they incur in performing services and procedures in a nonhospital setting.

(B) Providers are only entitled to the additional payment if the services and procedures were provided in the physician’s office, group practice office, or a clinic as described in rule 5101:3-4-02.2 of the Administrative Code. A provider is not entitled to the incentive payment if a hospital billed the department on an UB-92 claim form for hospital services provided in conjunction with the services and procedures performed by the physician or a clinic-based physician.

(C) The amount of the additional payment will be either fifteen, twenty-five, or fifty dollars as specified in appendix A to this rule. If multiple covered surgical procedures are performed on the same patient on the same date of service in the office or clinic setting, the reimbursement shall be as follows:

(1) The surgical procedures will be reimbursed as described in paragraphs (D) and (E) of rule 5101:3-4-22 of the Administrative Code.

(2) The additional payment will be one hundred per cent of the additional amount for the primary procedure, fifty per cent of the additional amount for the secondary procedure, and twenty-five per cent for all subsequent procedures.

(D) The additional payment will be paid for those services and procedures contained in appendix A to this rule and performed in the office or clinic setting.

(E) For the procedures listed in appendix A to this rule the medicaid maximum payment shall be the provider’s billed charge or the rate set forth in appendix DD of rule 5101:3-1-60 of the Administrative Code plus the additional payment set forth in appendix A to this rule, whichever is less.

APPENDIX A

OFFICE AND CLINIC INCENTIVE PROGRAM

The following procedures are approved for additional payment in the office and clinic incentive program.

REIMBURSEMENT FOR ADDITIONAL CPT CODE DESCRIPTION OFFICE COSTS

11200 Romoval of Skin Tags, Multiple Fibrocutaneous Tags, Any Area, up to and Including 15 Lesions $50

11740 Evacuation Subungual Hematoma $15

11975 Insertion Implantable Contraceptive Capsules $50

11976 Removal Without Reinsertion, Implantable Contraceptive Capsules $50

11977 Removal and Reinsertion of Implantable Contraceptive Capsules $50

12001 Simple Repair Of Superficial Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk And/Or Extremities (Including Hands And Feet); 2.5 CM Or Less $15

12002 Simple Repair Of Superficial Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk And/Or Extremities (Including Hands And Feet); 2.6 CM To 7.5 CM $15

12004 Simple Repair Of Superficial Wounds Of Scalp, Neck, Axillae, External Genitalia, Trunk And/Or Extremities (Including Hands And Feet); 7.6 CM To 12.5 CM $15

12011 Simple Repair Of Superficial Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.5 CM Or Less $15

12013 Simple Repair Of Superficial Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.6 CM To 5.0 CM $15

12014 Simple Repair Of Superficial Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 5.1 CM To 7.5 CM $15

12015 Simple Repair Of Superficial Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 7.6 CM To 12.5 CM $15

12031 Layer Closure Of Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 2.5 CM Or Less $15

12032 Layer Closure Of Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 2.6 CM To 7.5 CM $15

12034 Layer Closure Of Wounds Of Scalp, Axillae, Trunk And/Or Extremities (Excluding Hands And Feet); 7.6 CM To 12.5 CM $15

12041 Layer Closure Of Wounds Of Neck, Hands, Feet And/Or External Genitalia; 2.5 CM Or Less $15

12042 Layer Closure Of Wounds Of Neck, Hands, Feet And/Or External Genitalia; 2.6 CM To 7.5 CM $15

12044 Layer Closure Of Wounds Of Neck, Hands, Feet And/Or External Genitalia; 7.6 CM To 12.5 CM $15

12051 Layer Closure OF Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.5 CM Or Less $15

12052 Layer Closure Of Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 2.6 CM To 5.0 CM $15

12053 Layer Closure Of Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 5.1 CM To 7.5 CM $15

12054 Layer Closure Of Wounds Of Face, Ears, Eyelids, Nose, Lips And/Or Mucous Membranes; 7.6 CM To 12.5 CM $15

15850 Removal of Sutures Under Anesthesia (Other Than Local), Same Surgeon $25

15851 Removal of Sutures Under Anesthesia (Other Than Local), Other Surgeon $25

19101 Biopsy of breast $25

19120 Excision of cyst, fibroadenoma or other, benign tumor $25

20200 Biopsy, Muscle; Superficial $25

20205 Biopsy, Muscle; Deep $25

20220 Biospy, bone, trochar or needle, superficial $25

20225 Biopsy, Muscle; Deep (Vertebral Body, Femur) $25

20240 Biopsy, Excisional; Superficial (e.g., Ilium, Sternum, Spinous Process, Ribs, Trochanter Of Femur) $25

20670 Removal of implant; superficial $25

20680 Removal buried wire, nail deep $50

25110 Excision of lesion of tendon sheath $50

25111 Excision Of Ganglion, Wrist (Dorsal Or Volar); Primary $25

25246 Injection Procedure for Wrist Arthography $50

25337 Reconstruction for Stabilization of Unstable Distal Ulna or Distal Radioulnar Joint, Secondary by Soft Tissue Stabilization with or Without Open Reduction of Distal Radioulnar Joint $50

27095 Injection Procedure for Hip Arthography, with Anesthesia $50

28108 Excision or Curretage of Bone Cyst or Benign Tumor, Phalanges of Foot $50

28124 Partial Excision (Craterization, Saucerization, or Diaphysectomy) of Bone (E.g., for Osteomyelitis or Dorsal, Bossing), Phalanax of Toe $50

28126 Resection, Partial or Complete, Phalangeal Base, Single Toe, Each $50

28153 Resection, Head of Phalanx, Toe $50

28230 Tenotomy, Open, Flexor, Foot, Single or Multiple (Separate Procedure) $50

28232 Tenotomy, Open, Flexor; Toe Single (Separate Procedure) $50

28234 Tenotomy, Open, Extensor, Foot or Toe $50

28270 Capsulotomy; Metatarsophalangeal Joint, with or Without Tenorrhaphy, Single, Each Joint (Separate Procedure) $50

28272 Capsulotomy; Interphalangeal Joint, Single, Each Joint (Separate Procedure) $50

27345 Excision synovial cyst $50

28290 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; Simple Exostectomy (Silver Type Procedure) $25

28292 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; Keller, McBride Or Mayo Type Procedure $25

28293 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; Resection Of Joint With Implant $50

28294 Halux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; With Tendon Transplants (Joplin Type Procedure) $50

28296 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; With Metatarsal Osteotomy (e.g., Mitchell, Chevron, Or Concentric Type Procedures) $50

28297 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; Lapidus Type Procedure $50

28298 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; By Phalanx Osteotomy $50

28299 Hallux Valgus (Bunion) Correction, With Or Without Sesamoidectomy; By Other Methods (e.g., Double Osteotomy) $50

29870 Arthroscopy $25

31525 Diagnostic laryngoscopy $50

31622 Bronchoscopy, diagnostic, rigid bronchoscope $50

37609 Ligation Or Biopsy, Temporal Artery $25

38500 Biopsy lymph node $25

40830 Closure of Laceration, Vestibule of Mouth; 2.5 cm or Less $25

43200 Esophagoscopy, rigid or fiberoptic, diagnostic $50

43202 Esophagoscopy, Rigid Or Flexible Fiberoptic (Specify); For Biopsy And/Or Collection Of Specimen By Brushing Or Washing $50

43220 Esophagoscopy, Rigid Or Flexible Fiberoptic (Specify); For Dilation, Direct, Any Method $50

43226 Esophagoscopy, Rigid Or Fle xible Fiberoptic (Specify); For Insertion Of Wire To Guide Dilation $50

43234 Upper Gastrointestinal Endoscopy, Simple Primary Examination (e.g., With Small Diameter Flexible Fiberscope) $50

43235 Upper Gastrointestinal Endoscopy Including Esophagus, Stomach, And Either The Duodenum And/Or Jejunum As Appropriate; Complex Diagnostic $50

43245 Upper Gastrointestinal Endoscopy Including Esophagus, Stomach, And Either The Duodenum And/Or Jejunum As Appropriate; For Dilation Of Gastric Outlet For Obstruction $50

43247 Upper Gastrointestinal Endoscopy Including Esophagus, Stomach, And Either The Duodenum And/Or Jejunum As Appropriate; For Removal Of Foreign Body $50

43251 Upper Gastrointestinal Endoscopy Including Esophagus, Stomach, And Either The Duodenum And/Or Jejunum As Appropriate; For Removal Of Polypoid Lesion(s) $50

45330 With biopsy and/or collection of specimen by brushing or washing $25

45378 Colonscopy, fiberoptic, beyond splenic flexure; diagnostic procedure $25

45380 Colonoscopy, Fiberoptic, Beyond Splenic Flexure; With Biopsy And/Or Collection Of Specimen By Brushing Or Washing $25

45382 Colonoscopy, Fiberoptic, Beyond Splenic Flexure; With Control Of Hemorrhage (e.g., Electrocagulation, Laser Photocagulation) $25

45383 Colonoscopy, Fiberoptic, Beyond Splenic Flexure; With Ablation Of Tumor Or Mucosal Lesion (e.g., Electrocoagulation, Laser Photocoagulation, Hot Biopsy/Fulguration) $25

45385 Colonoscopy, Fiberoptic, Beyond Splenic Flexure; With Removal Of Polypoid Lesion(s) $25

49080 Peritoneocentesis, Abdominal Paracentesis, Or Peritoneal Lavage (Diagnostic Or Therapeutic); Initial $25

50205 Renal Biopsy; by Surgical Exposure of Kidney $50

50394 Injection Procedure for Pyelography (As Nephostogram, Pyelostogram, Antegrade Pyeloureterograms) Through Nephrostomy or Pyelostomy Tube, or Indwelling Ureteral Catheter $50

54161 Circumcision, surgical excision, not newborn $25

55700 Biopsy, Prostate; Needle or Punch, Single or Multiple, Any Approach $50

58560 Hysteroscopy, Surgical; with Division or Resection of Intrauterine Septum (Any Method) $50

58562 Hysteroscopy, Surgical; with Removal of Impacted Foreign Body $50

57520 Biopsy of cervix $25

58120 Dilation and curettage, diagnostic or therapeutic $50

58805 Drainage of Ovarian Cyst(s), Unilateral or Bilateral, (Separate Procedure(s); Abdominal Approach $50

59812 Treatment Of Spontaneous Abortion, Any Trimester, Completed Surgically $50

59820 Treatment Of Missed Abortion, Completed Surgically, First Trimester $50

59821 Treatment Of Missed Abortion, Completed Surgically, Second Trimester $50

62270 Spinal Punchure, Lumbar, Diagnostic $25

69105 Biopsy External Auditory Canal $50

69610 Tympanic Membrane Repair, with or Without Site Preparation or Perforation for Closure, with or Without Patch $50

69205 Removal Foreign Body From External Auditory Canal; With General Anesthesia $50

69420 Myringotomy $25

69421 Myringotomy, Requiring General Anesthesia $50

96440 Chemotherapy Administration Into Plural Cavity, Requiring Thoracentesis $50

96445 Chemotherapy Administration Into Peritoneal Cavity, Requiring Paracentesis $50

96450 Chemotherapy Administration Into CNS (e.g., Intrathecal), Requiring Lumbar Puncture $50

96542 Chemotherapy Injection, Subarachnoid or Intraventricular via Subcutaneous Reservoir, Single or Multiple Agents $25

Effective: 03/30/2008

R.C. 119.032 review dates: 01/08/2009

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 3/20/84, 1/4/88, 9/1/89, 5/1/90, 5/25/91, 4/1/92 (Emer) 7/1/92, 12/31/92 (Emer) 4/1/93, 3/30/95, 3/21/96, 1/1/01, 1/8/04

5101:3-4-10 Pregnancy related services.

(A) “Pregnancy related services” identified in paragraphs (B) to (F) of this rule are optional preventive health services available to all medicaid-eligible women. These services are intended to promote positive birth outcomes by supplementing regular obstetrical care. Services identified in paragraphs (G) and (H) of this rule are covered services for women who need therapeutic intervention to prevent poor birth outcome.

(1) Pregnancy related services may be delivered by physicians, hospitals, clinics, rural health clinics, outpatient health facilities, federally qualified health centers, and advanced practice nurses who are eligible medicaid providers. When provided, these services must be billed in accordance with the specific billing requirements and procedures for the provider type of the rendering provider as specified in Chapter 5101:3 of the Administrative Code.

(2) These services may also be delivered, but not billed directly, by health care professionals (e.g., dietitians, social workers) who are not eligible medicaid providers, if the services provided are within the professional’s scope of practice and the professional is employed by or under contract with an eligible medicaid provider.

(3) Pregnancy related services may be provided in a patient’s home or at the provider’s practice site.

(4) When billing for pregnancy related services listed in this rule with the exception of the predelivery visit to a pediatrician or other primary care provider, follow the billing instructions listed in this paragraph: