5101:3-4-25 Laboratory and radiology services.

(A) Laboratory.

The department will reimburse physicians for laboratory procedures that are necessary in the treatment of a patient's condition in accordance with Chapter 5101:3-11 of the Administrative Code.

(B) Radiology

The department will reimburse physicians and certain other providers for covered radiology services in accordance with paragraphs (B)(1) to (B)(9) of this rule.

(1) The department recognizes a professional component and a technical component for each radiological procedure. When both components are performed by one provider, they are recognized as the total (radiological) procedure.

(2) X-rays and documentation of all results of radiological procedures must be maintained on file for a period of six years. In addition, x-rays must be of sufficient quality to ensure ease of diagnosis and must be marked with the patient's name and dated for ready identification.

(3) Modifiers.

When billing for radiology services, providers must bill using the appropriate modifiers. Appendix DD to rule 5101:3-1-60 of the Administrative Code identifies which current procedural terminology(CPT) modifier applies to a particular procedure code.

"26 Professional component only"

"TC Technical component only"

"Unmodified Total procedure (both technical and professional components)"

(4) Professional component.

(a) The department will directly reimburse a radiologist the professional component when the radiologist performs the initial interpretation of a radiological examination.

(b) The department will directly reimburse a radiologist or cardiologist for the professional component when the radiologist or cardiologist interprets a radiological procedure that has already been interpreted by another physician. In this case, the radiologist's or cardiologist's interpretation is a specialist's evaluation (of the interpretation of the treating physician) whose findings could affect the course of treatment initiated or cause a new course of treatment to begin.

(c) Reimbursement is not allowed for an interpretation of a radiologic procedure performed by the attending, treating, or emergency room physician after a radiologist's or cardiologist's interpretation. Such a service would be considered a part of the physician's overall workup or treatment of the patient and reimbursed as part of the visit.

(d) A physician providing radiological services in an inpatient hospital, an outpatient hospital, or an emergency room setting may bill only for the professional component.

(e) To bill for the professional component only use the appropriate procedure code modified by 26 (e.g., 7001026).

(5) Technical component.

(a) The department will reimburse a physician/provider for only the technical component if:

(i) The physician personally performed the service or the service was performed by an employee of the physician/provider;

(ii) The professional component was performed by another physician/provider; and

(iii) The service was performed in a setting other than an inpatient hospital, an outpatient hospital or an emergency room.

(b) To bill for the technical component only, use the appropriate procedure code modified by TC (e.g., 70010TC).

(6) Total procedure.

(a) The department will reimburse a physician for the total procedure when the radiologist or treating physician performs the professional and technical components of a radiological procedure in a setting other than an inpatient hospital, an outpatient hospital, or an emergency room.

(b) The department will reimburse any other non hospital provider for the total procedure when:

(i) The physician who performed the professional component has an employment or contractual arrangement for the provider to bill for the professional services; and

(ii) The technical component was performed in a setting other than an inpatient hospital, an outpatient hospital, or an emergency room.

(c) To bill for the total procedure, use the appropriate procedure code unmodified (e.g., 70000).

(7) Radiation treatment services.

(a) For reimbursement for the professional services associated with radiation treatments, the provider must bill the appropriate procedure code for clinical treatment management modified by the modifier 26.

(i) One of the weekly clinical management codes must be billed for each five fractions provided regardless of the time interval used in delivering the five fractions.

(ii) The radiation therapy management code must be billed "by report" when the complete course of treatment consists of one or two fractions.

(b) The radiation treatment delivery codes are considered technical only procedures and may be reimbursed to a non-hospital provider only if the service was provided in a non-hospital setting and the code was billed without a modifier.

(8) Reimbursement of radiology procedures.

(a) Radiology procedures have a key listed identifying the professional and technical split in appendix DD to rule 5101:3-1-60 of the Administrative Code. This key specifies the split between the professional and technical component. For example, the indicator K indicates that fifty per cent of the fee amount is for professional services and fifty per cent is paid for technical services.

(b) Reimbursement for radiology procedures provided by non-hospital providers shall be the lesser of the provider's billed charge, or:

(i) For the total procedure, the price listed in appendix DD to rule 5101:3-1-60 of the Administrative Code;

(ii) For the professional component, the price listed in appendix DD to rule 5101:3-1-60 of the Administrative Code, multiplied by the percentage indicated by the code for the professional component; or

(iii) For the technical component, the price listed in appendix DD to rule 5101:3-1-60 of the Administrative Code multiplied by the percentage indicated by the code for the technical component.

(c) Payment for conscious sedation is bundled into the payment for the related surgical or radiological procedure and is not reimbursed separately by the department.

(9) Reimbursement for supplies for radiologic procedures.

(a) Effective for dates of service on or after January 1, 2006, the department will reimburse a physician or other eligible (non-hospital) provider in accordance with rule 5101:3-1-60 of the Administrative Code for supplies for radiologic procedures performed in a non-hospital setting.

(b) Codes for supplies for radiologic procedures are invalid for all hospital places of service.

(10) Mammography services.

(a) Payment may be made for screening mammography services if the services are provided by a facility having a certificate issued by the food and drug administration (FDA) and the services are provided in accordance with:

(i) All federal, state, and local laws pertaining to the provision and quality assurance standards of radiological and mammography services; and

(ii) The frequencies and conditions set forth in paragraph (B)(10) (b) of this rule.

(b) Frequency and conditions of coverage.

(i) No payment may be made for a screening mammography provided to a medicaid recipient under thirty-five years, unless a woman is at high risk of developing breast cancer. The patient's medical records must clearly document the patient's immediate risk of developing breast cancer at an age less than thirty-five.

(ii) One screening mammography may be paid for a medicaid recipient over the age of thirty-four and under the age of forty.

(iii) One screening mammography every twelve months may be paid for a medicaid recipient who is over the age of thirty-nine.

(c) Mammographies provided for the diagnosis and treatment of women who show clinical symptoms indicative of breast cancer are covered regardless of the recipient's age.

(d) Under the medicaid program, mammography services may be provided by the following Ohio medicaid providers as long as the provider complies with all applicable federal, state and local laws governing mammography services:

(i) Physicians and physician group practices;

(ii) Clinics;

(iii) Rural health clinics (RHCS);

(iv) Outpatient health facilities (OHFS);

(v) Federally qualified health clinics (FQHCS);

(vi) Hospitals; and

(vii) Independent physiological laboratories.

Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 6/3/83, 10/1/83 (Emer), 12/29/83, 1/1/86, 5/9/86, 6/16/88, 1/13/89 (Emer), 4/13/89, 9/1/89, 5/1/90, 2/17/91, 5/25/91, 12/30/93 (Emer), 3/31/94, 5/2/94 (Emer), 7/1/94, 12/30/94 (Emer), 3/30/95, 3/21/96, 7/1/96, 12/31/97 (Emer), 3/19/98, 12/31/98 (Emer), 3/31/99, 1/1/01, 7/1/03, 9/1/05, 12/30/05 (Emer), 3/27/06