5101:3-8-26 Anesthesiologist assistant (AA) services: eligible providers and coverage and limitations.

(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