(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 institutional 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 lesser of 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.
R.C. 119.032 review dates: 01/07/2011 and 03/01/2016
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, 3/30/08, 12/30/10 (Emer)