5101:3-4-03 Physician assistants.

(A) Definitions.

(1) "Supervision," for the purposes of this rule, is defined in accordance with Chapter 4730-1 of the Administrative Code.

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

(3) "Supervising physician," for the purpose of this rule, means the physician(s) responsible for the physician assistant's performance, and with whom the physician assistant has a supervision agreement approved by the state medical board of Ohio, in accordance with Chapter 4730-1 of the Administrative Code.

(B) Coverage and limitations.

(1) Services/procedures provided by a physician assistant are covered by medicaid only if:

(a) The services are provided in accordance with Chapter 4730-1 of the Administrative Code;

(b) The services are:

(i) Specified in section 4730.09 of the Revised Code with the exception of the services listed in paragraph (C)(5) of this rule; or

(ii) The services are approved by the state medical board as special services for that physician assistant if the services provided by the physician assistant are beyond the scope of services authorized under division (A) of section 4730.09 of the Revised Code;

(c) The services are within the scope of practice of the physician assistant's supervising physician;

(d) The services are covered by the department in accordance with rule 5101:3-1-60 of the Administrative Code and not specifically excluded from coverage in accordance with paragraph (C) of this rule;

(e) The physician assistant is employed by or under contract with a physician, physician group practice, or clinic; and

(f) The physician assistant provides services in compliance with all applicable state laws (each physician assistant and his/her supervising physician(s) is responsible for compliance with applicable state laws).

(2) The department may reimburse a physician assistant, physician, physician group practice, or clinic for physician assistant evaluation and management services commensurate with his/her training, experience, the scope of practice of the physician assistant's supervising physician, and the physician supervisory plan.

(C) Provisions applicable to medicaid payment for physician assistant services:

(1) Medicaid payment may be made to the physician assistant directly, or to the physician, physician group practice, or clinic employing or contracting with the physician assistant who is providing services in accordance with this rule.

(2) Physician assistant services are subject to the site differential payments in all places of service specified in rule 5101:3-4-02.2 of the Administrative Code.

(3) A physician assistant, physician, physician group practice, or fee-for-service clinic must bill for services provided by a physician assistant using the appropriate procedure code with the UD modifier except as provided in paragraph (C)(4) of this rule.

(4) A physician assistant, physician, physician group practice, or fee-for-service clinic must bill for services provided by a physician assistant using the appropriate procedure code without the UD modifier if:

(a) A physician also provided distinct and identifiable services during a visit or encounter; or

(b) The services are the type usually provided by medical personnel below the physician assistant and/or advanced practice nurse level of education (e.g., collection of specimens, immunizations).

(5) The department will reimburse physician assistants, physicians, physician group practices, and fee-for-service clinic for services provided by a physician assistant:

(a) The lesser of the provider's billed charge or eighty-five per cent of the medicaid maximum for all services billed in accordance with paragraph (C)(3) of this rule; and

(b) The lesser of the provider's billed charge or one hundred per cent of the medicaid maximum for all services billed in accordance with paragraph (C)(4) of this rule.

(6) A physician assistant, physician, physician group practice, or clinic will not be reimbursed for the following when provided by a physician assistant:

(a) Assistant-at-surgery services;

(b) Visits and/or procedures provided on the same date of service by both a physician assistant and his/her supervising physician, employing physician, employing physician group practice, or employing clinic and billed as separate procedure codes;

(c) Consultations and critical/intensive care services (although physician assistants may provide services that are valuable components of a consultation, ultimately a consultation is the responsibility of a physician); and

(d) Services prohibited in accordance with rule 4730-1-03 of the Administrative Code.

(7) A physician assistant, physician, physician group practice, or clinic may be directly reimbursed for services provided in a nursing facility or intermediate care facility for the mentally retarded by a physician assistant, as described in rule 5101:3-3-19 of the Administrative Code.

(8) Reimbursement for services provided by a hospital-employed physician assistant is available only to hospitals.

Effective: 07/01/2012
R.C. 119.032 review dates: 04/16/2012 and 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02 , 5111.053
Rule Amplifies: 5111.01 , 5111.02 , 5111.021 , 5111.053 , Section 309.37.53 of Am. Sub. H.B. 153
Prior Effective Dates: 9/1/89, 4/1/92 (Emer), 7/1/92, 4/1/93, 11/1/01, 10/1/03, 2/16/09