Chapter 5101:3-8 Limited Practitioner Services

(A) Individuals licensed under state of Ohio law to practice a limited branch of medical or remedial care are eligible to participate in the medicaid program within the scope of that limited practice as defined by state law, provided that the individual is authorized by the rules of the department to be a provider for those services, and holds a currently valid provider agreement. (Reference Chapter 5101:3-1 of the Administrative Code for an explanation of conditions for a provider agreement.)

(B) A professional association (group medical practice) consisting solely of limited practitioners is also considered eligible if it is an association organized under Chapter 1785. of the Revised Code with the limitations stated in paragraphs (A)(2)(a) to (A)(2)(f) of rule 5101:3-4-01 of the Administrative Code except the term “physician” as defined in rule 5101:3-4-01 of the Administrative Code shall be replaced with the term “limited practitioner” as specified in paragraphs (C)(1) to (C)(5) of this rule.

(C) Providers of limited medical/remedial care thus eligible include:

(1) Individual chiropractor licensed under Chapter 4734. of the Revised Code for medicaid-covered services within the scope of his or her practice as defined by state law.

(2) Individual physical therapist licensed under sections 4755.40 to 4755.56 of the Revised Code for medicaid-covered services within the scope of his or her practice as defined by state law. The provider must also be a participant under the medicare program and must maintain an independent practice as defined and determined under medicare.

(3) Individual occupational therapist licensed under sections 4755.04 to 4755.13 of the Revised Code for medicaid-covered services within the scope of his or her practice as defined by state law. The provider must also be a participant under the medicare program and must maintain an independent practice as defined and determined under medicare.

(4) Individual mechanotherapist licensed under section 4731.15.1 of the Revised Code for medicaid-covered services within the scope of his or her practice as defined by state law.

(5) Individual psychologist licensed under Chapter 4732. of the Revised Code for medicaid-covered services within the scope of his or her practice as defined by state law. The provider must also be a participant under medicare.

(D) Eligible providers of physical therapy, occupational therapy, and psychology services also include the following Ohio medicaid providers:

(1) Fee-for-service ambulatory health care clinics as defined in Chapter 5101: 3-13 of the Administrative Code;

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

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

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

(5) Hospitals as defined in Chapter 5101: 3-2 of the Administrative Code; and

(E) Eligible providers of chiropractic services include the providers listed in paragraphs (D)(1), (D)(2), and (D)(4) of this rule.

Effective: 01/01/2008

R.C. 119.032 review dates: 10/16/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.029

Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 7/1/02

(A) Definitions.

Additional definitions are described in Chapter 5101:3-34 of the Administrative Code.

(1) “Direct supervision” or “directly supervised” means that the physical therapist must be present throughout the time the physical therapist assistant is providing the service and immediately available to provide assistance and direction throughout the time the physical therapist assistant is performing services.

(B) Medicaid eligible provider of physical therapy services.

(1) Physical therapy services described in this rule may be billed by the following limited practitioners who are currently licensed and working within the scope of their practices as defined by state law and have executed the standard Ohio medicaid provider agreement:

(a) Physical therapists in independent practice as set forth in rule 5101:3-8-01 of the Administrative Code and licensed under Chapter 4755. of the Revised Code; and

(b) Mechanotherapists as set forth in rule 5101:3-8-01 of the Administrative Code and licensed under Chapter 4731. of the Revised Code.

(2) Other independently practicing providers authorized to be reimbursed by the department for physical therapy are described in Chapter 3-34 of the Administrative Code.

(3) Physical therapy services provided in a school, hospital, or long term care facility must be billed by the school, hospital, or long term care facility in which the services were provided.

(C) Coverage and limitations.

Medicaid coverage and limitations of physical therapy services are described in Chapter 5101:3-34 of the Administrative Code.

(1) Modality guidelines.

(a) Supervised modalities must have direct (one-on-one) provider to consumer contact. The provider must be licensed to provide the modality and must be directly supervised by a medicaid-authorized prescriber or therapist.

(b) The following modalities are considered part of the associated therapy procedure or medical encounter and are not separately reimbursable:

(i) Electrical stimulation-unattended; and

(ii) Iontophoresis therapy.

(c) Certain modalities are considered part of an associated physical therapy procedure or medical encounter and are not separately reimbursable.

(D) Provider claims, billing, payment, and reimbursement are addressed in Chapters 5101:3-1, 5101:3-2, and 5101:3-3 of the Administrative Code.

Replaces: 5101:3-8-02

Effective: 01/01/2008

R.C. 119.032 review dates: 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021

Prior Effective Dates: 4/7/77, 9/19/77, 12/21/77, 12/30/77, 7/1/02

(A) Definitions.

Additional definitions are described in rule 5101:3-34-01.1 of the Administrative Code.

(1) “Direct supervision” or “directly supervised” means that the occupational therapist must be present throughout the time the occupational therapy assistant is providing the service and immediately available to provide assistance and direction throughout the time the occupational therapy assistant is performing services.

(B) Medicaid eligible provider of occupational therapy services.

(1) Occupational therapy services described in this rule may be billed by occupational therapists in independent practice who are currently licensed under Chapter 4755. of the Revised Code, who are working within the scope of their practice as defined by state law and set forth in rule 5101:3-8-01 of the Administrative Code, and who have executed the standard Ohio medicaid provider agreement.

(2) Other independently practicing providers authorized to be reimbursed by the department for occupational therapy are described in Chapter 3-34 of the Administrative Code.

(3) Occupational therapy services provided in a school, hospital, or long term care facility must be billed by the school, hospital, or long term care facility in which the services were provided.

(C) Coverage and limitations.

Medicaid coverage and limitations of occupational therapy services are described in Chapter 5101:3-34 of the Administrative Code.

(1) Modality guidelines.

(a) Supervised modalities must have direct (one-on-one) provider to consumer contact. The provider must be licensed to provide the modality and must be directly supervised by a medicaid-authorized prescriber or therapist.

(b) The following modalities are considered part of the associated therapy procedure or medical encounter and are not separately reimbursable:

(i) Electrical stimulation-unattended; and

(ii) Iontophoresis therapy.

(c) Certain modalities are considered part of an associated occupational therapy procedure or medical encounter and are not separately reimbursable.

(D) Provider claims, billing, payment, and reimbursement are addressed in Chapters 5101:3-1, 5101:3-2, and 5101:3-3 of the Administrative Code.

Effective: 01/01/2008

R.C. 119.032 review dates: 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.029

For dates of service from January 1, 2004 through December 31, 2007, psychology services specified in paragraphs (C) to (F) of this rule were not covered medicaid services for adults twenty-one years of age and older when services were provided by an independent psychologist and independent group psychologist practices.

Psychology services not provided by independent psychologists (for example, services provided in an outpatient hospital facility) continued to be covered medicaid services.

Effective for dates of service from January 1, 2008, psychology services for adults twenty-one years of age and older when provided by an independent psychologist and independent group psychologist practices for adults are covered services subject to the coverage and limitations as specified in this rule.

(A) Definitions:

(1) “Independent psychologist” means a psychologist licensed under Chapter 4732. of the Revised Code who provides services on his/her own, free of administrative and professional control of an employer such as an institution, physician, or agency.

(a) The psychologist treats his/her own patients and has a valid Ohio medicaid provider agreement to bill directly for his/her services. A psychologist practicing in an office located in an institution may be considered an “independently practicing psychologist” when both of the following conditions are met:

(i) The office is in a separately identifiable part of the facility which is used solely as the psychologist’s office and is not viewed as extending through the entire institution; and

(ii) The psychologist has a private practice, e.g provides services to consumers outside of the institution as well as to institutionalized consumers. The private practice is not owned, in part or in total by the institution.

(b) A psychologist seeing nursing home consumers cannot bill medicaid using his/her psychologist provider number. Services to nursing home consumers are covered through the nursing facility’s cost report and described in paragraph (G) of rule 5101:3-3-19 of the Administrative Code.

(2) “Provider-based psychologist” means a psychologist employed by a provider listed in paragraph (E) of rule 5101:3-8-01 of the Administrative Code.

(3) “Psychological tests” means tests which address personality disorders, intellectual function, behavioral or addictive disorders, or screening tests for organic brain disease.

(4) “Neuropsychological tests” means tests for patientsconsumers suffering from cognitive defects due to neurological conditions.

(5) “Direct supervision” is defined in rule 5101:3-4-02 of the Administrative Code.

(6) “Group psychotherapy” means psychological treatment involving two or more consumers participating together in the presence of one or more psychologists who facilitate interactions to effect targeted changes in the behavior of a consumer.

(B) Services must be personally provided by a licensed psychologist meeting the qualifications in section 4732.10 of the Revised Code. Services must be medically necessary for the diagnosis and treatment of an illness or injury to be a covered medicaid service. All services must be within the scope of practice for a licensed psychologist as defined in Chapter 4732. of the Revised Code. To be reimbursed for psychology services:

(1) Services must be billed under the individual psychologist’s provider number only when the services are provided by an independently practicing psychologist as defined in paragraph (A) of this rule.

(2) Services must be billed by a psychology group practice only if the psychologist is employed by a group medical practice as defined in rule 5101:3-8-01 of the Administrative Code.

(3) Services must be billed under the hospital’s or clinic’s medicaid provider number when the psychologist is provider-based as defined in paragraph (A)(2) of this rule.

(4) Effective with services provided on and after October 1, 2003, when billing for any service, the licensed psychologist must bill the appropriate procedure code for the service rendered and modify the code by the “AH” modifier to signify that the service was personally provided by a licensed psychologist.

(5) When services are provided to inpatients in a hospital or to nursing home residents regardless of the billing arrangement, the psychologist cannot submit a claim as an individual psychologist or as a psychology group medical practice.

(C) Covered psychological testing services:

(1) Psychological and neuropsychological testing are covered when performed to assist in establishing a psychological or neuropsychological disorder. The consumer’s medical record must support the medical necessity of the tests performed.

(2) For dates of service beginning on or after January 1, 2006, the department will pay in accordance with rule 5101:3-1-60 of the Administrative Code for procedure codes 96101 through 96118 for medically necessary psychological testing services personally performed by a licensed psychologist.

(D) Covered therapeutic services:

(1) For services provided on or after July 1, 2002, the department will pay eighty-five per cent of the value listed in rule 5101:3-1-60 of the Administrative Code for each procedure code for services performed by a licensed psychologist. The following procedure codes must be billed for therapeutic services:

(a) For individual psychotherapy provided in the office, outpatient clinic, outpatient hospital, or home, bill the following codes:

(i) 90804 Individual psychotherapy, insight-oriented, in office, outpatient facility, twenty to thirty minutes face-to-face contact with patient.

(ii) 90806 Individual psychotherapy, insight-oriented, in office, outpatient facility forty to fifty minutes face-to-face contact with patient.

(iii) 90808 Individual psychotherapy, insight-oriented, in office, outpatient facility seventy-five to eighty minutes face-to-face contact with patient.

(iv) 90810 Individual psychotherapy, interactive, in an office or outpatient setting, twenty to thirty minutes face-to-face contact with patient.

(v) 90812 Individual psychotherapy, interactive, in an office or outpatient setting, forty-five to fifty minutes face-to-face contact with patient.

(vi) 90814 Individual psychotherapy, interactive, in an office or outpatient setting, seventy-five to eighty minutes face-to-face contact with patient.

(b) Family psychotherapy is covered only where the primary purpose of such counseling is the treatment of the consumer’s condition, not the treatment of the family members. For family or group psychotherapy, bill the following codes:

(i) 90846 Family psychotherapy (without consumer present).

(ii) 90847 Family psychotherapy (with consumer present).

(iii) 90849 Multiple-family group psychotherapy.

(iv) 90853 Group psychotherapy as defined in paragraph (A)(5) of this rule (other than of a multiple-family group).

(E) Diagnostic interview examination

(1) For dates of service on and after October 1, 2003, a diagnostic interview examination will be a covered service.

(2) To be reimbursed, bill code 90801. This code is not time-based and can be billed only as one unit of service.

(3) The department will pay eighty-five per cent of the medicaid maximum for an examination personally performed by a licensed psychologist.

(F) Services provided by clinical psychology doctoral level interns completing required internships.

For services provided by clinical psychology doctoral level interns completing required internships to be reimbursed to a psychologist, the following conditions must be met:

(1) The psychologist billing medicaid must have a letter on file covering the dates of services of the doctoral level internship from the doctoral level program;

(2) The graduate doctoral level intern must be under the direct supervision of the licensed psychologist responsible for the consumer’s care;

(3) The licensed psychologist responsible for the consumer’s care must have face-to-face contact with the consumer during the consumer’s visit and must confirm that the service provided by the doctoral level intern was appropriate; and

(4) The consumer’s medical record must show that the requirements for reimbursement were met and the licensed psychologist responsible for the consumer’s care reviewed, countersigned, and dated the notes in the medical record at least every week so that it is documented that the licensed psychologist is responsible for the consumer’s care.

(G) Non-covered psychological services:

The following psychologists’ services are not covered by the Ohio medicaid program:

(1) All services listed in paragraph (F) of rule 5101:3-4-29 of the Administrative Code describing mental and emotional disorders;

(2) Self-administered or self-scored tests of cognitive function;

(3) Services provided by a school psychologist in facilities regulated by the state board of education;

(4) Biofeedback therapy;

(5) Services which are not personally performed by a psychologist with whom the department has a provider agreement and who is licensed under Chapter 4732. of the Revised Code;

(a) With the exception of the provisions stated in paragraph (F) of this rule, services provided by licensed individuals with whom the department does not have an individual provider agreement are not reimbursable even though the covered services are provided under the personal supervision of licensed psychologist with whom the department does have a provider agreement.

(b) Services provided by unlicensed individuals under the personal supervision of a licensed psychologist are not reimbursable.

(6) Services provided to nursing home residents are reimbursable through the nursing facility’s cost report and shall not be billed directly by the psychologist as specified in paragraph (G) of rule 5101:3-3-19 of the Administrative Code;

(7) Services provided to consumers in an inpatient or outpatient hospital setting are not covered in this rule but are covered in Chapter 5101:3-2 of the Administrative Code;

(8) Services unrelated to the treatment of a specific medical complaint or services which are not medically necessary as defined in Chapter 5101:3-1 of the Administrative Code;

(9) Services determined by another third-party payer (especially medicare Title XVIII) as not medically necessary are not covered;

(a) All psychological services denied by medicare; and

(b) The thirty-seven point five per cent outpatient psychiatric payment limitation subtracted from medicare claims.

(H) Limitations:

(1) Psychological testing is limited to a maximum of eight hours per twelve-month period per consumer in a non-hospital setting.

(2) Therapeutic visits and diagnostic interview examinations in excess of a combined twenty-five dates of service per consumer in a twelve-month period in an non-hospital setting are not covered.

(3) Diagnostic interview examinations will be limited to one per consumer per twelve month period and may not be billed on the same date of service as a therapeutic visit.

(I) Documentation:

The consumer’s medical record must support the medical necessity of the tests and/or therapies performed. The records should contain the following documentation at a minimum:

(1) The date the service was provided;

(2) The type of tests and/or type of therapies performed, including test results;

(3) The face-to-face time spent with the consumer on testing or therapy;

(4) Time spent interpreting and reporting for testing codes specified in rule 5101:3-1-60 of the Administrative Code under the title “Central Nervous System (CNS) Test”;

(5) A written interpretation by a psychologist of the tests and/or psychotherapy sessions should be in the consumer’s record;

(6) The discipline and signature of the professional providing the service; and

(7) All documentation provisions for therapeutic services outlined in paragraph (H) of rule 5101:3-4-29 of the Administrative Code shall apply to therapeutic services provided by a psychologist with the exception that a psychologist does not need to have the treatment plan signed and dated by a physician prior to initiating therapy.

Effective: 01/01/2008

R.C. 119.032 review dates: 10/16/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.0112, 5111.02, 5111.021

Prior Effective Dates: 7/1/02, 8/17/03, 1/1/04, 12/30/05 (Emer), 3/27/06

For dates of service from January 1, 2004 through December 31, 2007, chiropractic services provided by chiropractic physicians were not covered medicaid services for adults twenty-one years of age and older.

(A) Definitions:

(1) “Subluxation” means an incomplete dislocation, off centering, misalignment, fixation, or abnormal spacing of the vertebrae anatomically, and must be demonstrated by x-ray film or other diagnostic test; and

(2) “Maintenance therapy” means therapy that is performed to treat a chronic, stable condition or to prevent deterioration.

(B) Treatment by means of manual manipulation of the spine to correct a subluxation which exceeds normalcy is a covered service. The existence of the subluxation must be demonstrated either by a diagnostic x-ray or by physical examination, as described in paragraph (C) of this rule. Evidence must be retained as a part of the consumer’s medical record that a subluxation exists. The manual manipulation must have a direct therapeutic relationship to the consumer’s condition as documented in the medical record. The lack of documentation specifying the relationship between the consumer’s condition and treatment shall result in the service being nonreimburseable.

(C) At least two of the following criteria must exist and be documented to demonstrate a subluxation by physical examination. One of the two criteria must be asymmetry/misalignment or range of motion abnormality.

(1) Pain/tenderness evaluated in terms of location, quality and intensity;

(2) Asymmetry/misalignment identified on a sectional or segmental level;

(3) Range of motion abnormality; or

(4) Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.

(D) Covered chiropractic services shall be limited to the chiropractic procedures listed in paragraph (D)(1) of this rule and diagnostic x-rays meeting the provisions described in paragraph (D)(2) of this rule. The service must relate to the diagnosis and treatment of a significant health problem in the form of a neuromusculoskeletal condition necessitating manipulative treatment.

(1) The chiropractic procedures listed below are covered under the medicaid program if the service is deemed medically necessary. The limit is one unit of service for each consumer for each date of service.

(a) Chiropractic manipulative treatment (CMT); spinal, one to two regions.

(b) Chiropractic manipulative treatment (CMT); spinal, three to four regions.

(c) Chiropractic manipulative treatment (CMT); spinal, five regions.

(2) Diagnostic x-rays to determine the existence of a subluxation are covered with certain limitations. Two units of service, as defined below, will be covered during any six-month period unless otherwise stated. For purposes of this rule, the six-month period begins on the date the diagnostic x-ray is taken and ends one hundred eighty days from the date. The covered units of service are as follows:

(a) Spine, entire; survey study, anterior-posterior, and lateral. Only two units per one year (three hundred and sixty five days) period are covered.

(b) Spine, cervical; antero-posterior, and lateral.

(c) Spine, cervical; antero-posterior, and lateral; minimum of four views.

(d) Spine, cervical; antero-posterior, and lateral; complete, including oblique and flexion and/or extension studies.

(e) Spine, thoracic; anterior-posterior, and lateral views.

(f) Spine, thoracic; complete, including obliques; minimum of four views.

(g) Spine, thoracolumbar; antero-posterior lateral views.

(h) Spine, lumbosacral; antero-posterior, and lateral views.

(i) Spine, lumbosacral; complete, with oblique views; and

(j) Spine, lumbosacral; complete, including bending views.

(E) Limitations of coverage:

(1) Spinal axis aches, strains, sprains, nerve pains, and functional mechanical disabilities of the spine are considered to provide therapeutic grounds for chiropractic manipulative treatment. Most other diseases and disorders do not provide therapeutic grounds for chiropractic manipulative treatment. Examples of non-covered diagnoses are multiple sclerosis, rheumatoid arthritis, muscular dystrophy, sinus problems and pneumonia.

(2) Repeat x-rays or other diagnostic tests in consumers with chronic, permanent conditions will not be considered medically necessary and are not a covered service.

(3) If there is no reasonable expectation that the continuation of treatment would improve or arrest deterioration of the condition within a reasonable and generally predictable period of time, coverage will be denied.

(4) Continued repetitive treatments without an achievable and clearly defined goal will be considered maintenance therapy and will not be considered covered services.

(5) Once the maximum therapeutic benefit has been achieved for any given condition, ongoing therapy is considered maintenance therapy which is not considered medically necessary.

(6) When services are performed more frequently than generally accepted by peers, chiropractic manipulation will be considered excessive and will be denied as not medically necessary.

(F) There must be documentation to support each service billed. Documentation should exist in the consumer’s medical record and must verify that the services billed were rendered and that the services were medically necessary.

(1) The following information should be documented in the consumer’s medical record on the initial visit for a new condition:

(a) Consumer’s history;

(b) Consumer’s chief complaint;

(c) Subjective findings from physical examination including evaluations of the musculoskeletal and nervous systems;

(d) Objective findings including x-ray results, if given;

(e) Diagnosis;

(f) Treatment plan which includes the following:

(i) Goals;

(ii) Plans for continued treatment including duration and frequency of visits; and

(iii) Objective measures that will be used to evaluate the effectiveness of treatment.

(2) The following information should be documented on periodic reassessments:

(a) Consumer’s status on each visit date including how the patient’s consumer’s condition has changed since the last treatment;

(b) Review of how the chief complaint has changed since the last visit; and

(c) Results of physical exam.

(3) On each visit, the treatment given on each visit date must be documented including the specific region(s) manipulated.

(G) The following services are not covered:

(1) Visits in excess of thirty dates of service per consumer per twelve-month period in an outpatient setting if the consumer is under the age of twenty- one;

(2) Effective for dates of service on or after January 1, 2008, visits in excess of fifteen dates of service per consumer per twelve-month period in an outpatient setting if the consumer is twenty-one years of age or older.

(3) Services rendered to consumers in an inpatient or outpatient hospital setting are not covered in this rule but are covered in Chapter 5101:3-2 of the Administrative Code;

(4) Services unrelated to the treatment of the specific medical complaint, services unnecessary for the treatment of an ailment, and treatment of a preventative medicine nature;

(5) Services determined by another third-party payer (especially medicare Title XVIII) as not medically necessary. Services denied by medicare will be considered medically unnecessary by the department and will not be considered covered services by medicaid;

(6) X-rays, except for those delineated in paragraph (B)(2) of this rule;

(7) Services which are not personally performed by the chiropractic physician with whom the department has a provider agreement:

(a) Services provided by licensed individuals with whom the department does not have an individual provider agreement are not reimbursable even though the covered services are provided under the personal supervision of a licensed chiropractic physician with whom the department does have a provider agreement.

(b) Services provided by unlicensed individuals under the personal supervision of a licensed chiropractic physician are not reimbursable.

(c) Services provided by students during an internship are not covered services.

(8) Any service other than manual manipulation for treatment of subluxation of the spine and x-rays as described in paragraph (D) of this rule are not covered services. The following are examples of services (not an all-inclusive list) that, when performed or ordered by the chiropractor, are excluded from coverage:

(a) Maintenance therapy;

(b) Laboratory test;

(c) Evaluation and management services;

(d) Physical therapy;

(e) Traction;

(f) Supplies;

(g) Injections;

(h) Drugs;

(i) Diagnostic studies;

(j) Orthopedic devices;

(k) Equipment used for manipulation; and

(l) Any manipulation which the x-ray or other tests does not support the primary diagnosis.

Effective: 01/01/2008

R.C. 119.032 review dates: 10/16/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.0112, 5111.02, 5111.021, Section 309.30.60 of Am. Sub. House Bill 119, 127th General Assembly

Prior Effective Dates: 2/10/86, 12/31/86 (Emer), 03/22/97, 07/01/02, 1/1/04

(A) All the definitions set forth in rule 4723-08-01 of the Administrative Code apply to rules 5101:3-8-20 to 5101:3-8-23 of the Administrative Code unless otherwise indicated.

(B) Definitions.

(1) “Fee-for-service clinics” are clinics that are eligible and bill the department as ambulatory health clinics in accordance with Chapter 5101:3-13 of the Administrative Code.

(2) “Cost-based clinics” are clinics that are eligible and bill the department as a rural health clinic (RHC), a federally qualified health center (FQHC), or an outpatient health facility (OHF) in accordance with Chapters 5101:3-16, 5101:3-28 and 5101:3-29 of the Administrative Code, respectively.

(3) “Advanced practice nurse” for the purpose of rules 5101:3-8-21 to 5101:3-8-23 of the Administrative Code is a registered nurse who holds a certificate of authority issued by the board of nursing to practice as a certified nurse practitioner, clinical nurse specialist, or certified nurse midwife in accordance with section 4723.42 of the Revised Code and meets the criteria set forth in rule 5101:3-8-21 of the Administrative Code.

Effective: 01/01/2008

R.C. 119.032 review dates: 05/15/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50

Prior Effective Dates: 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

(A) A certified nurse practitioner approved under section 4723.42 of the Revised Code is eligible to become an Ohio medicaid provider as an individual nurse practitioner upon the execution of an Ohio medicaid provider agreement if both of the following are met:

(1) The certified nurse practitioner holds a valid certificate of authority issued by the Ohio board of nursing in accordance with section 4723.42 of the Revised Code.

(2) The certified nurse practitioner is certified by a national certifying organization approved by the Ohio board of nursing as at least one of the following:

(a) An adult nurse practitioner;

(b) A family nurse practitioner;

(c) A pediatric nurse practitioner;

(d) An obstetrical-gynecological/women’s health care nurse practitioner;

(e) A neonatal nurse practitioner;

(f) A gerontological nurse practitioner;

(g) An acute care nurse practitioner;

(h) A psychiatric nurse practitioner; or

(i) A palliative care nurse practitioner.

(B) A clinical nurse specialist approved under section 4723.42 of the Revised Code is eligible to become an Ohio medicaid provider as an individual clinical nurse specialist upon execution of an Ohio medicaid provider agreement if both of the following are met:

(1) The clinical nurse specialist holds a valid certificate of authority issued by the Ohio board of nursing in accordance with section 4723.42 of the Revised Code.

(2) The clinical nurse specialist is certified by a national certifying organization approved by the Ohio board of nursing as at least one of the following:

(a) An oncology clinical nurse specialist;

(b) A clinical nurse specialist in adult health;

(c) A gerontological clinical nurse specialist;

(d) A psychiatric clinical nurse specialist;

(e) A palliative care nurse specialist;

(f) An acute care clinical nurse specialist; or

(g) A pediatric clinical nurse specialist.

(C) Clinical nurse specialists and certified nurse practitioners not meeting the criteria in paragraph (A)(1) and (A)(2), or (B)(1) and (B)(2), of this rule, as applicable, are not eligible for enrollment as a provider in the medicaid program.

(D) A certified nurse midwife approved under section 4723.42 of the Revised Code is eligible to become an Ohio medicaid provider as an individual nurse midwife upon execution of an Ohio medicaid provider agreement if all of the following are met:

(1) The certified nurse midwife holds a valid certificate of authority issued by the Ohio board of nursing in accordance with section 4723.42 of the Revised Code.

(2) The certified nurse midwife has completed an accredited course of study.

(3) The certified nurse midwife is certified by the American college of nurse-midwives, the American midwifery certification board, or the American college of nurse midwives certification council.

(E) An advanced practice nurse group is eligible to enroll in the medicaid program if it meets the criteria as a professional group as defined in paragraph (C) of rule 5101:3-1-17 of the Administrative Code.

(F) Advanced practice nurses enrolled in the medicaid program may be members of any physician group practice enrolled in the Ohio medicaid program.

(G) Out-of-state advanced practice nurses providing services to Ohio medicaid recipients must be licensed, certified, or authorized as required by the state in which the recipient is located at the time the service is provided. In addition, out-of-state advanced practice nurses must meet the provisions of rule 5101:3-1-11 of the Administrative Code addressing out-of-state coverage.

(H) Any advanced practice nurse practicing in Ohio who applies to become a medicaid provider for the first time after January 1, 2003, must possess a master’s degree in nursing.

Effective: 01/01/2008

R.C. 119.032 review dates: 05/15/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50

Prior Effective Dates: 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

(A) Advanced practice nurses enrolled in the Ohio medicaid program may practice in a variety of practice or employment arrangements as specified in the nurse’s standard care arrangement in accordance with section 4723.431 of the Revised Code. Whether an advanced practice nurse or a group of advanced practice nurses is entitled to direct reimbursement under the Ohio medicaid program is dependent entirely on the practice or employment arrangement of the advanced practice nurse or group.

(B) Practice arrangements.

(1) Independent practice.

An “advanced practice nurse” is considered to be in an independent practice if the medical services rendered to a patient are the responsibility of an advanced practice nurse who is in solo practice or a member of an advanced practice nurse group practice and the practice is free of the fiscal, administrative, and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or any other medicaid provider. “Free of professional control” does not mean that the advanced practice nurse practices in the absence of a standard care arrangement. Each advanced practice nurse, including those in independent practice as defined in this rule, must maintain a standard care arrangement as required by section 4723.431 of the Revised Code.

(2) Provider-based practice.

An “advanced practice nurse” is considered to be in a provider-based practice if the advanced practice nurse is under the fiscal, administrative and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or any other medicaid provider through an employment, a contractual, or any other legally binding arrangement. Advanced practice nursing services provided in provider-based practices are considered incidental to the employing or contractual provider (i.e., as physician services if provided in a physician-based practice, as clinic services if provided in a clinic-based practice, as hospital services if provided in a hospital-based practice, etc.).

(C) Reimbursement.

(1) Services provided by advanced practice nurses are subject to the site differential payments set forth in rule 5101:3-4-02.2 of the Administrative code and the office incentive payments set forth in rule 5101:3-4-09 of the Administrative Code.

(a) The total reimbursement for services and procedures subject to the site differential payment is either the provider’s billed charge or the reimbursement rate established in paragraphs (C)(3) and (C)(4) of this rule multiplied by the site differential percentage rate, whichever is less.

(b) The total reimbursement for services and procedures subject to the office incentive payment is either the provider’s billed charges or the reimbursement rate established in paragraphs (C)(3) and (C)(4) of this rule plus the incentive payment rate, whichever is less.

(2) Separate reimbursement is not available for any service included in the global payment of another service (e.g., evaluation and management services provided for post-operative care), whether the global payment was made directly to the advanced practice nurse or to another medicaid provider.

(3) Only advanced practice nurses who practice in an independent practice arrangement are eligible to bill and receive direct reimbursement under the Ohio medicaid program. For independent practices, reimbursement is the lesser of the provider’s billed charge or one of the following:

(a) Eighty-five per cent of the medicaid maximum when services are provided in a hospital setting; or

(b) One hundred per cent of the medicaid maximum when services are provided in a nonhospital setting.

(4) Services provided by advanced practice nurses in provider-based practices are reimbursable only to the employing or contracting provider.

(a) For individual physician-based practices, group physician-based practices, fee-for-service clinic-based practices, or hospital-based practices;, reimbursement for advanced practice nursing services is the lesser of the provider’s billed charge or one of the following:

(i) Eighty-five per cent of the medicaid maximum when services are provided by an advanced practice nurse in the following places of service: inpatient hospital, outpatient hospital, or hospital emergency department; or

(ii) One hundred per cent of the medicaid maximum when services are provided by an advanced practice nurse in any nonhospital place or service.

(b) For RHC-based, FQHC-based and OHF-based practices, reimbursement for advanced practice nursing services is the medicaid maximum set forth in Chapters 5101:3-16, 5101:3-28, and 5101:3-29 of the Administrative Code, respectively.

(c) For all other nonhospital, provider-based practices, reimbursement for advanced practice nursing services is bundled into the payment for that provider type and is the maximum allowed under the medicaid program for the services rendered by that provider type (e.g., services provided by a nurse practitioner employed by a home health agency would be bundled into the payment for a home health service).

(d) When services incident to advanced practice nurse services are provided by an individual who is not an advanced practice nurse in an office or clinic setting, the services rendered must be within the scope of licensure (if licensure is required) of the individual who is not an advanced practice nurse or a service for which the individual is legally authorized to provide under Ohio law and documented in the patient’s medical records.

(i) The services rendered by the individual who is not an advanced practice nurse must be rendered under the direct supervision of the advanced practice nurse. The records must be reviewed and countersigned by the supervising advanced practice nurse.

(ii) “Direct supervision” in the advanced practice nurse’s office or clinic setting means-that the advanced practice nurse must be present in the office suite throughout the time the individual who is not an advanced practice nurse is providing the service and immediately available to provide assistance and direction throughout the time the individual who is not an advanced practice nurse is performing services. Direct supervision does not mean the advanced practice nurse must be in the same room while the individual who is not an advanced practice nurse is providing services. The availability of the advanced practice nurse by telephone or the presence of the advanced practice nurse somewhere in the institution does not constitute availability.

(iii) All of the provisions relating to direct supervision described in rule 5101:3-4-02 of the Administrative Code must be met.

(5) Hospital-based advanced practice nurses.

(a) For hospital-based practices, separate reimbursement is available to hospitals for professional services provided by advanced practice nurses only if the requirements set forth in paragraph (C)(5)(c) of this rule are met. Reimbursement for professional services provided by hospital-based advanced practice nurses is in accordance with paragraph (C)(4)(a) of this rule. In addition, certain services are subject to the site differential payment in accordance with paragraph (C)(1) of this rule.

(b) Services provided by advanced practice nurses that include teaching, research, administration, supervision of professional and/or technical personnel, supervision of nursing and advanced practice nursing students, service on hospital committees, and other hospital-based activities that are of benefit to patients, generally do not meet all of the requirements set forth in paragraph (C)(5)(c) of this rule.

(i) Such services are reimbursable only as hospital services and are bundled into the hospital’s inpatient or outpatient facility payment in accordance with Chapter 5101:3-2 of the Administrative Code; and

(ii) The portion of the expenses associated with the provision of the type of services identified in paragraph (C)(5)(b) of this rule by an advanced practice nurse, may be included on the hospital cost report.

(c) Reimbursement for services rendered directly to, and for the benefit of, individual patients by advanced practice nurses who are employed by or under contract with a hospital is separately reimbursable to the hospital on a fee-for-service basis as advanced practice nursing services (i.e., in addition to the inpatient or outpatient hospital facility payment) if the following requirements are met:

(i) The services are personally furnished for an individual patient by an advanced practice nurse who is currently enrolled as an Ohio medicaid provider.

(ii) The services contribute directly to the diagnosis or treatment of an individual patient.

(iii) The services ordinarily require performance by a physician or an advanced practice nurse.

(iv) The services are not the type of services routinely performed by registered nurses or other hospital-employed nonphysicians.

(v) For services identified in paragraphs (C)(5)(c)(i) to (C)(5)(c)(iv) of this rule, documentation must exist that demonstrates the advanced practice nurse’s involvement in the service rendered. A countersignature alone in the records is not considered sufficient documentation of advanced practice nursing services.

(vi) The portion of the expenses associated with the provision of the type of services identified in paragraphs (C)(5)(c)(i) to (C)(5)(c)(iv) of this rule by advanced practice nurses are excluded from the hospital cost report.

(6) In an institutional setting, advanced practice nurses will only be reimbursed by the medicaid program for the services that have been personally rendered by the advanced practice nurse.

Effective: 01/01/2008

R.C. 119.032 review dates: 05/15/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50

Prior Effective Dates: 9/24/83, 4/1/88, 5/15/89, 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

(A) The coverage of services provided by advanced practice nurses shall be limited only to the extent that the condition of the patient and/or the limited scope of practice of an advanced practice nurse as it is recognized under Ohio law warrants the intervention and/or care of a physician in a capacity other than one of advisory, collaborating, or for the purposes of prescribing pharmaceuticals or medical devices when the advanced practice nurse lacks prescriptive authority.

(B) Chapter 5101:3-14 of the Administrative Code and all the rules set forth in Chapter 5101:3-4 of the Administrative Code that pertain to services a physician is legally authorized to perform under Ohio law shall apply to advanced practice nurses except, the term “physician” as it is defined in rule 5101:3-4-01 of the Administrative Code shall be replaced with the term “advanced practice nurse” as it is defined in rule 5101:3-8-21 of the Administrative Code.

(C) In addition to being subject to the applicable rules set forth in Chapter 5101:3-4 of the Administrative Code, advanced practice nurses are subject to the following coverage and limitations:

(1) For services provided in a teaching setting for advanced practice nurses, paragraphs (A) and (E)(2) in rule 5101:3-4-05 of the Administrative Code shall apply except the term “physician” in this rule shall be replaced by the term “advanced practice nurse” and the term “resident, intern, or fellow” shall be replaced by the term “individual in training for an advanced practice nursing certification.”.

(2) Under no circumstances will an advanced practice nurse be eligible to bill or be reimbursed for the following evaluation and management CPT code: 99223,

(3) Consultations performed by an advanced practice nurse are covered.

(4) Except when precluded by Ohio law, inpatient hospital evaluation and management services are covered only if the advanced practice nurse is acting in the capacity of the patient’s “primary treating provider” for the day and no physician is acting concurrently as the primary treating provider, and billing for evaluation and management services. For purposes of this rule, “primary treating provider” is a physician or advanced practice nurse who is responsible for managing the patient’s inpatient hospital care for that day. “Primary treating provider” does not include a sub-specialist provider who may be treating the patient concurrently for specialty care, (e.g. a nephrologist).

(5) Antepartum services may be provided by advanced practice nurses who are certified in an advanced practice nurse specialty that is qualified to perform antepartum services.

(6) “Covered nurse midwifery services” are defined as those services that constitute the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically. Only advanced practice nurses who are certified nurse midwives may perform and bill for deliveries. In addition, the following services are noncovered when performed by nurse midwives, except in unavoidable, emergency situations:

(a) Management of an acute obstetric emergency, including any obstetric operation;

(b) Version or delivery of breech or face presentation; and

(c) Use of forceps;

(7) Therapeutic injections, prescribed drugs, diagnostic and therapeutic services, laboratory services, and radiology services are covered as an advanced practice nursing service only if the service was ordered and/or prescribed by a physician, an advanced practice nurse, or any other provider who has the authority to order and/or prescribe the services under, and in accordance with, Ohio law.

(8) With the exception of those laboratory procedures listed as physician-performed microscopy procedures (PPMP), laboratory services that require performance by a pathologist or a physician who is regarded as a specialist in pathological or hematological medicine (e.g., physician professional services associated with the gross or microscopic examination of surgical pathology tissues), are not covered if they are performed by an advanced practice nurse.

(9) Professional radiology or diagnostic and therapeutic services are covered by an advanced practice nurse if the advanced practice nurse is within his or her scope of practice.

(10) If a physician and an advanced practice nurse provide the same covered service, (e.g. any evaluation and management service), or participate in the provision of a global/all-inclusive service that involves multiple visits on the same or different days, only one provider is entitled to reimbursement for the service.

(a) Unless otherwise agreed upon by the two providers, the physician or the employing provider of the physician shall be the provider entitled to reimbursement if the condition of the patient and/or the limited scope of practice of an advanced practice nurse warrants the intervention and/or care of a physician in a capacity other than one of advisory, collaborating, or for the purpose of prescribing pharmaceuticals, medical devices, or other diagnostic and therapeutic services when the advanced practice nurse lacks the prescriptive authority required.

(b) Separate reimbursement is not available for the physician’s supervision of or collaboration with an advanced practice nurse. Any cost associated with the supervisory role of a physician is the responsibility of the advanced practice nurse or advanced practice nurse group if the advanced practice nurse is in an independent practice arrangement, or the responsibility of the employing provider if the advanced practice nurse is in a provider-based practice arrangement.

(D) The following services are noncovered:

(1) Emergency room visit codes 99284 and 99285 are not covered if billed by an advanced practice nurse who is in an independent practice as defined in rule 5101:3-8-22 of the Administrative Code.

(2) All services exceeding the policies and limitations defined in Chapters 5101:3-1, 5101:3-4 and 5101:3-14 of the Administrative Code and rules 5101:3-8-20 and 5101:3-8-25 of the Administrative Code;

(3) All services exceeding the scope of practice of an advanced practice nurse under, and in accordance with, Ohio law;

(4) Any service exceeding the scope of practice of an advanced practice nurse as defined in the standard care arrangement;

(5) Services determined by the department as not medically necessary as defined in rule 5101:3-1-01 of the Administrative Code or that are duplicative in respect to a service provided concurrently by a physician or other valid medicaid provider;

(6) Assistant-at-surgery services;

(7) Services of residents, interns, and fellows provided in a teaching setting supervised by an advanced practice nurse; and

(8) All services itemized as noncovered in rule 5101:3-4-28 of the Administrative Code.

Effective: 01/01/2008

R.C. 119.032 review dates: 05/15/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50

Prior Effective Dates: 9/24/83, 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

(A) Any certified registered nurse anesthetist (CRNA) who holds a current, valid certificate of authority issued under, and in accordance with, Ohio law entitling the holder to practice as a nurse anesthetist is eligible to participate in Ohio’s medicaid program and provide covered CRNA services upon the execution of the Ohio medicaid provider agreement.

(B) A CRNA group practice must meet the criteria as a professional group practice as defined in paragraph (C) of rule 5101:3-1-17 of the Administrative Code and is organized for the purpose of providing CRNA services.

(C) A CRNA who is licensed or holds a current certificate, or similar document under another state’s law entitling the holder to practice as a nurse anesthetist, is eligible to participate in Ohio’s medicaid program and provide covered CRNA services as long as the following are met:

(1) The services are rendered to eligible Ohio recipients in the state in which the CRNA is authorized to practice;

(2) The provider of CRNA services has a currently valid provider agreement with the department; and

(3) The provisions in rule 5101:3-1-11 of the Administrative Code addressing out-of-state coverage are met.

(D) A CRNA that meets the criteria set forth in paragraphs (A) to (C)(2) of this rule is entitled to receive an Ohio medicaid legacy number. CRNA services may be billed if the following conditions are met:

(1) The provisions of paragraph (B) or (C) of rule 5101:3-8-25 of the Administrative Code are met; and

(2) The provisions outlined in rule 5101:3-1-17 of the Administrative Code are met.

Effective: 01/01/2008

R.C. 119.032 review dates: 05/15/2007 and 01/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50

Prior Effective Dates: 3/30/95, 6/1/02

(A) The department will reimburse a CRNA for general, regional or supplementation of local anesthesia services (monitored anesthesia care as described in paragraph (I) of rules 5101:3-4-21 of the Administrative Code) provided during a surgical or diagnostic procedure. Anesthesia services include the basic preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the usual monitoring procedures. Anesthesia services include ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry as usual monitoring procedures. Unusual monitoring procedures (e.g., intra-arterial, central venous and swan-ganz) are not included and may be separately billed and reimbursed as long as the performance of these services are not limited by Ohio law.

(B) A CRNA is considered to be self-employed if the CRNA is in a solo practice and the practice is free of the fiscal, administrative, and professional control of a CRNA group practice, an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider type.

(C) An independent CRNA group practice is a practice composed solely of two or more CRNAS enrolled under the medicaid program and the practice is free of the fiscal, administrative, and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider.

(D) Reimbursement for anesthesia services provided by a CRNA may be made directly to a CRNA provider type only if the services were provided by a self-employed CRNA or by a CRNA employed by an independent CRNA group practice.

(E) A CRNA’s provider number may be listed on a medicaid invoice under the following circumstances only:

(1) When a claim is being submitted for anesthesia services provided by a CRNA who either is self-employed or a member of an independent CRNA group practice;

(2) When a crossover (“F-type”) claim is being submitted, in accordance with paragraph (G)(2) of this rule, for medicare co-insurance and deductible payments;

(3) When a claim is being submitted, in accordance with paragraph (H)(2) of this rule, for anesthesia services that were provided by a non-medically directed physician-employed CRNA; or

(4) When a claim is being submitted in accordance with paragraph (H)(1) of this rule, for anesthesia services that were provided by a medically-directed or medically-supervised physician-employed CRNA.

(F) A CRNA is considered to be:

(1) “Medically directed” if anesthesia services are provided with a physician who meets all of the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code;

(2) “Nonmedically directed” if anesthesia services are provided without a physician who meets all of the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code; and

(3) “Medically supervised” if anesthesia services are provided with a physician who meets all of the conditions set forth in paragraph (C) (4) of rule 5101:3-4-21 of the Administrative Code.

(G) Separate reimbursement will be made for the medicare coinsurance and deductible amounts due for medicare covered CRNA services provided to a patient who is dually eligible for medicare and medicaid, even if direct reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g, hospital-employed CRNA services, physician-employed CRNA services, etc.).

(1) The co-insurance and deductible payments should normally be made through the automatic crossover mechanism.

(2) If the claims did not get paid through the automatic crossover mechanism, the provider must submit a medicaid crossover “F-type 6780” claim, in accordance with the crossover billing instructions except that the CRNA’s provider number must be submitted as the rendering provider and the employing provider number must be submitted as the pay to provider.

(H) The following CRNA reimbursement policies apply when services are provided to medicaid patients who are not also covered under medicare.

(1) Reimbursement of anesthesia services provided by a medically directed or medically supervised physician-employed CRNA.

When anesthesia services are provided by a CRNA who is under the employment of an individual or group physician practice and medical direction was provided by a physician in the practice, reimbursement for the services of the CRNA and the directing physician is paid to the employing physician or physician group practice as described in paragraph (H)(3)(b)(ii) of rule 5101:3-4-21 of the Administrative Code. For reimbursement, the physician who provided the medical direction would be listed as the rendering provider and the appropriate modifier indicating medical direction listed in paragraph (D)(1) of rule 5101:3-4-21 of the Administrative Code must be billed.

(2) Reimbursement of anesthesia services provided by a non-medically directed and non-medically supervised physician-employed CRNA.

(a) When anesthesia services are provided by a CRNA who is under the employment of an individual or group physician practice and medical direction was not provided by a physician in the practice, reimbursement for the services of the CRNA is reimbursable only to the employing physician or physician group practice.

(b) For reimbursement:

(i) The provider number of the employing individual physician practice or the employing physician group practice must be listed in the group practice space on the invoice;

(ii) The provider number of the CRNA must be listed in the rendering provider space on the invoice; and

(iii) The appropriate anesthesia code must be modified with the QZ modifier.

(3) Reimbursement of anesthesia services provided by hospital-employed CRNAs.

Direct reimbursement is not available for anesthesia services provided by a hospital employed CRNA. The reimbursement for the services provided by the CRNA is bundled into the facility payment made to the hospital. When a physician provides medical direction to a CRNA who is employed by the hospital, only the physician who provided the medical direction to the CRNA is entitled to reimbursement on a fee-for-service basis.

(4) Reimbursement of anesthesia services provided by self-employed CRNAs or CRNAs who are members of an independent CRNA group practice.

(a) Direct reimbursement for anesthesia services provided by a self-employed CRNA or a CRNA who is a member of an independent CRNA group practice is available whether or not the CRNA is medically directed by a physician.

(b) When a physician provides medical direction or medical supervision to a CRNA who is self-employed or a member of an independent CRNA group practice, reimbursement for the medical direction of the CRNA is also available to the physician and must be billed in accordance with rule 5101:3-4-21 of the Administrative Code.

(c) Reimbursement is not available for supervision services provided by a physician when the physician does not meet the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code.

(d) The CRNA or CRNA group practice must bill the code for the appropriate anesthesia code modified by either the QX or QZ modifier and report the total anesthesia time in minutes.

(i) If the CRNA was medically directed or medically supervised, the procedure code must be modified with the QX modifier.

(ii) If the CRNA was not medically directed, the procedure code must be modified with the QZ modifier.

(e) The policies contained in paragraphs (B), (D)(3), (E), (F) and (G) of rule 5101:3-4-21 of the Administrative Code also apply when anesthesia services are provided and billed by CRNAs.

(I) When a CRNA provides supervision and personal direction to a student nurse anesthetist involved in the provision of anesthesia services, reimbursement for the services of the CRNA is available in accordance with paragraph (G) of this rule. Reimbursement for the services of the student nurse anesthetist is bundled into the reimbursement made to the facility or hospital.

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: 3/30/95, 5/1/01

(A) Definitions.

(1) “Anesthesiologist assistant (AA) group practice” is two or more AAs organized for the purpose of providing AA services.

(2) “Anesthesiologist assistant” (AA) is an individual recognized under Chapter 4760. of the Revised Code as an AA.

(3) “Anesthesiologist-employed AA” is an AA employed by an anesthesiologist.

(4) “Hospital-employed AA” is an AA employed by a hospital.

(5) “Independent AA group practice” is two or more AAs organized for the purpose of providing AA services and free of the fiscal and administrative control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider.

(6) “Self-employed AA” is an AA in a solo practice that is free of the fiscal and administrative control of an independent AA group practice, an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider type.

(7) “Medical direction” means, in accordance with paragraph (C)(3)(a) of rule 5101:3-4-21 of the Administrative Code, that a physician who meets the requirement set forth in paragraph (C)(1) of rule 5101:2-4-21 of the Administrative Code utilizes the assistance of an AA in the performance of anesthesia services.

(B) Eligible providers.

(1) Any AA who holds a current valid certificate of registration issued by the state medical board may request an Ohio medicaid provider number.

(2) Any AA group practice whose members hold current valid certificates of registration issued by the state medical board may request an Ohio medicaid provider number.

(3) Only self-employed AAs and members of independent AA group practices may submit medicaid claims for direct reimbursement under their individual or AA group practice provider numbers.

(4) The department will directly reimburse an AA for anesthesia services only if the services were provided by the self-employed AA or member of the independent AA group practice.

(C) Coverage and limitations.

(1) The department will reimburse for general, regional, or supplementation of local anesthesia services of an AA, as described in rule 5101:3-4-21 of the Administrative Code, only when an AA is under the direct supervision and in the immediate presence of an anesthesiologist, in accordance with Chapter 4760. of the Revised Code.

(2) The department will not reimburse any medicaid provider for services not provided in accordance with state and local laws.

(3) Medicaid claims for services provided by an AA must include the appropriate anesthesia code modified by the QX modifier, indicating that the anesthesia services were provided under appropriate medical direction, and report the total anesthesia time in minutes.

(4) Self-employed AAs and independent AA group practices.

(a) Self-employed AAs and independent AA group practices may submit medicaid claims for direct reimbursement under their individual or group practice medicaid provider numbers only for services they provided as a self-employed AA or member of an independent AA group practice.

(b) The policies contained in paragraphs (B), (D)(3), (E), (F), and (G) of rule 5101:3-4-21 of the Administrative Code apply to self-employed AAs and members of independent AA group practices who provide anesthesia services and submit medicaid claims for direct reimbursement.

(c) Reimbursement for the medical direction of the AA is available to the anesthesiologist providing the medical direction and must be billed in accordance with rule 5101:3-4-21 of the Administrative Code.

(5) Anesthesiologist-employed AAs.

(a) The department will reimburse the employing anesthesiologist or anesthesia group practice in accordance with rule 5101:3-4-21 of the Administrative Code for services of an AA and the directing anesthesiologist when anesthesia services are provided by an AA who is under the employment of an individual or group physician practice and medical direction was provided by an anesthesiologist in the practice.

(6) Hospital-employed AAs.

(a) The department will not directly reimburse for anesthesia services provided by a hospital-employed AA. The department bundles reimbursement for the services provided by the AA into the facility payment made to the hospital.

(b) The department will reimburse the anesthesiologist who provided medical direction to the AA when the anesthesiologist provides medical direction to a hospital-employed AA.

(D) Separate reimbursement will be made for the medicare coinsurance and deductible amounts due for medicare covered AA services provided to a patient who is dually eligible for medicare and medicaid, even if direct reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g, hospital-employed AA services, etc.).

(1) The coinsurance and deductible payments should be made through the automatic medicare crossover process in accordance with rule 5101:3-1-05 of the Administrative Code.

(2) If claims are not paid through the automatic medicare crossover process, the provider must submit a medicaid crossover claim, in accordance with the crossover billing instructions.

Replaces: 5101:3-8-26

Effective: 09/01/2005

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: 05/01/2001

Effective for services provided on and after October 1, 2003, when billing for any service provided by an advanced practice nurse (APN), whether the APN is in independent practice or a provider-based practice as described in rule 5101:3-8-22 of the Administrative Code, all services provided by an APN must be billed with a modifier to denote the type of APN which provided the service:

(A) Bill the modifier “SA” e.g. 99201SA, if the APN is a nurse practitioner;

(B) Bill the modifier “SB” e.g. 99201SB, if the APN is a nurse mid-wife; or

(C) Bill the modifier “UC” e.g. 99201UC if the APN is a clinical nurse specialist.

HISTORY: Eff 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: 10/01/2008