Chapter 5160-4 Physician Services

5160-4-01 Physician services.

(A) Payment may be made for a covered service rendered by a physician only if the following conditions are met:

(1) The physician is currently enrolled as an Ohio medicaid provider;

(2) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the physician is licensed or authorized to practice; and

(3) The service is within the scope of practice of the physician's specialty.

(B) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a hospital or long-term care facility (i.e., a "facility-based" physician) only if the following additional conditions are met:

(1) The services contribute directly to the diagnosis or treatment of an individual patient;

(2) Any applicable requirements set forth in agency 5160 of the Administrative Code are satisfied; and

(3) The expenses associated with the provision of the professional services are excluded from the cost report of the facility.

(C) In addition to professional services, a facility-based physician often performs other services that are of benefit to patients in general (e.g., teaching; research; administration; supervision of professional or technical personnel, residents, interns, or fellows; or service on provider committees). Payment for such services may be made only to the employing or contracting provider.

(D) For the sole purpose of demonstrating eligibility for incentive payments made in accordance with Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA, Pub. L. No. 111-5 ), codified at 42 U.S.C. 1396b (February 1, 2017), and with the regulations published at 42 C.F.R. Part 495 (October 1, 2016), an optometrist operating within the appropriate scope of practice defined in section 4725.01 of the Revised Code is considered to be a physician.

Replaces: 5160-4-01

Cite as Ohio Admin. Code 5160-4-01

Effective: 10/1/2017
Five Year Review (FYR) Dates: 10/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 10/01/1983 (Emer), 12/29/1983, 09/01/1989, 03/26/2001, 09/01/2005, 10/25/2008, 08/02/2011, 12/02/2011 (Emer), 03/02/2012

5160-4-02 Supervision of professional services.

(A) Definitions.

(1) "Independent practitioner" is a practitioner who, under Ohio law, may provide professional medical services without supervision.

(2) "Non-independent practitioner" is a practitioner who, under Ohio law, may provide professional medical services only with supervision.

(3) "Supervision" is a collective term encompassing two types of professional oversight:

(a) A practitioner providing direct supervision is present in the practice setting, although not necessarily in the same room, and is immediately available to provide assistance and direction throughout the provision of services. Neither availability by telephone nor presence nearby outside the practice setting constitutes direct supervision.

(b) A practitioner providing general supervision is available, although not necessarily present in the practice setting, to provide assistance and direction throughout the provision of services. A practitioner who is not physically present must be located within a thirty-mile radius of the practice setting and must be immediately available for consultation by telephone.

(B) Coverage.

(1) Payment may be made for a service provided by a non-independent practitioner under general or direct supervision only if all of the following conditions are met:

(a) The non-independent practitioner functions in one of the following capacities:

(i) An employee of the supervising independent practitioner or of the practice in which the supervising independent practitioner participates; or

(ii) An independent contractor engaged by the supervising independent practitioner through a written agreement;

(b) The professional control exercised by the supervising independent practitioner or the practice of the supervising independent practitioner is the same for both employees and independent contractors; and

(c) The service was provided in connection with a covered professional service that represents an expense to the practice of the supervising independent practitioner.

(2) Payment may be made for a service provided by a non-independent practitioner under direct supervision only if at least one of the following additional conditions is met:

(a) The supervising independent practitioner personally rendered a professional service to initiate the course of treatment, to which the service performed by the non-independent practitioner is incidental; or

(b) The supervising independent practitioner rendered subsequent services at a frequency indicating continued participation in the management of the course of treatment.

(C) Limitations and exceptions.

(1) Services provided by independent practitioners who are employed by or under contract with another independent practitioner are not subject to the supervision provisions set forth in this rule.

(2) Nothing in this rule constitutes an exemption either from the requirement that services rendered must be within a practitioner's scope of licensure or practice or from any supervision requirement established in law, regulation, statute, or rule.

(3) No separate payment may be made for a professional service provided in a long-term care facility (LTCF), inpatient hospital, outpatient hospital, or hospital emergency department by a non-independent practitioner employed by the LTCF or hospital, even if an independent practitioner ordered the service.

Replaces: 5160-4-02

Cite as Ohio Admin. Code 5160-4-02

Effective: 10/1/2016
Five Year Review (FYR) Dates: 10/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 02/01/1980, 05/19/1986, 07/01/1987, 04/01/1988, 09/01/1989, 02/17/1991, 04/01/1992 (Emer), 07/01/1992, 05/02/1994 (Emer), 07/01/1994, 01/01/2001, 01/02/2004 (Emer), 04/01/2004, 02/16/2009, 07/01/2009

5160-4-02.1 "By-report" services.

(A) A "by-report" service is any service requiring manual review by the Ohio department of job and family services (ODJFS) or its designee to determine one or all of the following: if the service rendered was medically necessary and is reimbursable; the reimbursement rate on an unpriced procedure; or if special conditions or requirements were met. By-report services are set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(B) Claims for by-report services rendered must be submitted to ODJFS or its designee along with reports and documentation necessary to complete a coverage determination. Reports documenting the services or procedures performed, specific methodology or treatment programs, medical history and indications must be provided at a minimum. Coverage and reimbursement for by-report services rendered will be determined by ODJFS or its designee on a case-by-case basis.

(C) Unlisted (miscellaneous) healthcare common procedure coding system (HCPCS) codes are not covered. Unlisted HCPCS may be submitted by-report only when there is no other specific HCPCS code that adequately describes the procedure or service. If an unlisted code is submitted for review and ODJFS or its designee verifies that the unlisted code is appropriate, the claim and reports will be reviewed. If it is determined that an unlisted code was submitted in error because the procedure or service is described by one or more specific HCPCS codes, ODJFS or its designee shall deny the claim. If denied, the provider may submit a new claim using the specific current procedural terminology (CPT) code(s) or alphanumeric HCPCS code(s) for the procedure or service described in the reports. Codes that do not require by-report manual review shall be submitted directly to ODJFS by electronic data interchange (EDI) or though the ODJFS claims portal for adjudication and must not be submitted as a by-report claim for manual review.

Replaces: 5101:3-4- 02.1

Cite as Ohio Admin. Code 5160-4-02.1

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 5/19/86, 7/1/87, 4/1/88, 9/1/89, 1/1/01

5160-4-02.2 [Rescinded] Site differential payments and place of service.

Cite as Ohio Admin. Code 5160-4-02.2

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/07/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 05/25/1991, 04/01/1992 (Emer), 07/01/1992, 05/02/1994 (Emer), 07/01/1994, 01/01/2001, 09/01/2005, 07/01/2008, 08/02/2011, 12/31/2013

5160-4-03 Physician assistants.

(A) Definitions.

(1) "Physician assistant" means an individual who is licensed under Chapter 4730.of the Revised Code to provide services as a physician assistant to patients under the supervision, control, and direction of one or more physicians.

(2) "Physician" has the same meaning as in section 4730.01 of the Revised Code.

(3) "Health care facility" has the same meaning as in section 4730.01 of the Revised Code.

(4) "Service" has the same meaning as in section 4730.01 of the Revised Code.

(B) Eligible providers.

To receive medicaid payment, a physician assistant must hold a license to practice as a physician assistant issued under Chapter 4730. of the Revised Code and be enrolled as an Ohio medicaid provider.

(C) Coverage and limitations.

(1) Payment may be made for services rendered by a physician assistant only when the following conditions are met:

(a) The physician assistant is practicing under the supervision, control, and direction of a physician with whom the physician assistant has entered into a supervision agreement under section 4730.19 of the Revised Code.

(b) The physician assistant is practicing in accordance with the supervision agreement entered into with the physician who is responsible for supervising the physician assistant.

(2) When a physician assistant provides services in a health care facility, payment may be made for services the facility authorizes the physician assistant to provide for the facility.

(D) Claim payment.

(1) The department will pay physician assistants the lesser of the billed charge or eighty-five per cent of the medicaid maximum for covered services rendered by physician assistants.

(2) The department will pay for assistant-at-surgery services performed by physician assistants at the lesser of the billed charge or twenty-five percent of the medicaid maximum for the covered primary surgical procedure.

(3) Payment for services provided by a hospital-employed physician assistant will be made to the hospital.

Replaces: 5160-4-03

Cite as Ohio Admin. Code 5160-4-03

Effective: 1/1/2017
Five Year Review (FYR) Dates: 12/31/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.301
Rule Amplifies: 5164.02, 5164.301 , 5164.70
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, 7/1/2012

5160-4-04 Advanced practice registered nurse (APRN) services.

(A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP).

(B) Coverage.

(1) Unless a specific exception is noted, all other rules in agency 5160 of the Administrative Code that pertain to services rendered by a physician apply also to services rendered by an APRN.

(2) Payment may be made for a covered service rendered by an APRN only if the following conditions are met:

(a) The APRN is currently enrolled as an Ohio medicaid provider;

(b) The service is rendered to a medicaid-eligible Ohio recipient in a state in which the APRN is licensed or authorized to practice;

(c) The service is within the scope of practice of the APRN's specialty;

(d) The APRN personally rendered the service to an individual patient; and

(e) The service cannot be performed by someone who lacks the skills and training of an APRN.

(3) An APRN employed by or under contract with a physician, group practice, hospital, long-term care facility, or other medicaid provider must not submit a claim for service that would result in duplicate payment.

(C) Claim payment.

(1) Payment for a service rendered by a CRNA is made in accordance with rule 5160-4-21 of the Administrative Code.

(2) Payment for a service rendered by a CNS, CNM, or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list:

(a) For a service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum; or

(b) For a service rendered in a non-hospital setting, one hundred per cent of the medicaid maximum.

(3) Payment for services rendered by a hospital-employed APRN will be made to the hospital.

Replaces: 5160-8-22, 5160-8-23

Cite as Ohio Admin. Code 5160-4-04

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/24/1983, 04/01/1988, 05/15/1989, 03/01/1994 (Emer), 05/12/1994, 05/01/1997, 06/01/2002, 01/01/2008

5160-4-05 Services rendered under the supervision of a teaching practitioner.

(A) Definitions.

(1) "Resident" is an individual who participates in an approved graduate medical education (GME) program. The term includes both interns and fellows, but it excludes medical students enrolled at the undergraduate level.

(2) "Teaching practitioner" is a practitioner, other than a resident, who involves residents for pedagogical reasons in the care of the practitioner's patients.

(B) Coverage. Payment may be made to a teaching practitioner for services performed individually by a resident under supervision or jointly by the teaching practitioner and a resident. The following provisions apply:

(1) The teaching practitioner must provide the level of supervision appropriate to the procedure or service.

(2) The teaching practitioner need not be physically present when a resident performs a service if both of the following conditions are met:

(a) The resident provides one of the following low- or mid-level evaluation and management (E&M) services:

(i) Office or other outpatient visit, new patient;

(ii) Office or other outpatient visit, established patient;

(iii) Preventive medicine visit, new patient;

(iv) Preventive medicine visit, established patient; or

(v) E&M service reported as a prenatal visit; and

(b) The service is provided in a primary care center for which the following criteria are satisfied:

(i) The primary care center is located in a hospital outpatient department or other ambulatory care entity that receives GME payment for the time spent by residents in patient care duties; and

(ii) An authorized administrator attests in writing and maintains supporting documentation that the primary care center administers a residency program conforming to the medicare teaching practitioner policy set forth in 42 C.F.R. 415.174 (October 1, 2014) in at least one of the following specialties:

(a) Family practice;

(b) General internal medicine;

(c) Pediatrics;

(d) Obstetrics and gynecology; or

(e) Geriatric medicine.

(C) Limitation. No payment is made to a teaching practitioner for services rendered by a resident practicing outside a primary care center without the presence of the teaching practitioner.

(D) Accountability. The teaching practitioner assumes responsibility for the accuracy of the patient's medical file.

Replaces: 5160-4-05

Cite as Ohio Admin. Code 5160-4-05

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 07/01/1980, 10/01/1987, 09/01/1989, 01/01/2001, 09/01/2005, 02/12/2006

5160-4-06 Specific provisions for evaluation and management (E&M) services.

(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site in which the services are provided.

(1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitioners who are not hospital staff members is subject to the following conditions:

(a) Such services require direct face-to-face contact between a practitioner and the individual being transported, which begins when the practitioner assumes responsibility for the care of the individual at the point of pickup and ends when the receiving facility assumes this responsibility. Remote direction of emergency care en route (e.g., communication by radio with a physician located in a hospital) is not direct face-to-face contact.

(b) Routine monitoring and maintenance (e.g., the recording of vital information, pulse oximetry, the initiation of mechanical ventilation) is included; no separate payment is made.

(c) Services provided by other members of the transport team (the ambulance crew) cannot be reported by the practitioner as E&M services.

(2) Nursing facility (NF). Policies are set forth in Chapter 5160-3 of the Administrative Code. The periodic review of a NF resident's medical record, plan of care, or habilitation plan is part of overall medical direction, payment for which is made to the NF rather than to the practitioner.

(3) Federally qualified health center, outpatient health facility, or rural health clinic.

Policies are set forth in Chapter 5160-28 of the Administrative Code. Specific claim format requirements may apply.

(B) Service-related provisions.

(1) After-hours care. Additional payment may be made for E&M services provided in an office or clinic setting after regularly scheduled business hours.

(2) Bundled services. No separate payment is made for E&M services provided in conjunction with certain covered diagnostic or therapeutic procedures, which are identified in other rules in Chapter 5160-4 of the Administrative Code.

(3) Consultation. Payment may be made for a consultation provided by a licensed medical practitioner regarding the evaluation and management of a specific medical problem.

(a) The person who requests the consultation must be a licensed medical practitioner enrolled as a medicaid provider. For purposes of this rule, a medical visit initiated by someone other than a licensed medical practitioner (e.g., a patient, a family member, a teacher, a social worker) is not a consultation.

(b) The request for a consultation, the need for a consultation, the consultant's opinion, and any services that were ordered or performed in relation to the consultation must be documented in the patient's medical record.

(c) Follow-up visits initiated by a consultant for the purpose of evaluation and management of a patient's condition are E&M services rather than consultation.

(d) The referring practitioner must be identified on any claim for consultation that is submitted.

(4) Critical-care services. Payment for covered critical-care services provided by a single practitioner is limited to two hours per patient per day. This time limit does not apply to critical-care services rendered during the transportation of a critically ill or injured individual older than twenty-four months.

(5) Hospital observation services (including admission and discharge services).

Payment may be made for not more than twenty-two hours of medical observation of an individual who is treated in a hospital but does not require inpatient hospital admission.

(a) Emergency department services are not observation.

(b) If during observation the individual is admitted to the hospital as an inpatient, payment for the observation services depends on the role of the practitioner.

(i) If the observing practitioner continues as the individual's attending practitioner after admission, the observation services are treated as inpatient E&M services and must be reported as such on any claim submitted.

(ii) If the observing practitioner does not continue as the individual's attending practitioner after admission, the observation services are not reported as inpatient E&M services.

(6) Inpatient hospital visits following surgery. No separate payment is made for an E&M service provided within the postoperative period for a covered surgical procedure. The postoperative period, which is listed in appendix DD to rule 5160-1-60 of the Administrative Code, includes the day of surgery. The postoperative period for one surgical procedure may be extended by the performance soon afterward of another surgical procedure.

(C) Limitations.

(1) Payment for an E&M service that is not medically necessary in accordance with rule 5160-1-01 of the Administrative Code is subject to recovery.

(2) Concurrent care is the provision of service to one individual on one date of service by more than one practitioner in the same group practice. When concurrent care is provided, payment may be made only for one E&M service (i.e., the separate services are treated as though they were provided by the same practitioner for the same purpose) unless one of the following conditions applies:

(a) The services were provided for unrelated purposes;

(b) The practitioners had different specialties; or

(c) Each practitioner supplied knowledge or skill the other practitioners could not provide.

(3) E&M services in excess of twenty-four during a calendar year that are provided to an individual in an outpatient setting or a NF are subject to post-payment review. The following services are excluded from the calculation of the number of E&M services provided during a calendar year:

(a) Pregnancy-related services, which are described in rule 5160-21-04 of the Administrative Code;

(b) Early and periodic screening, diagnostic, and treatment (EPSDT) services;

(c) Inpatient hospital visits;

(d) Critical-care visits;

(e) An allergen immunotherapy service that is not provided in conjunction with an E&M service; and

(f) An E&M service provided for any of the following conditions or purposes:

(i) End-stage renal disease;

(ii) Chemotherapy or radiation therapy for malignancy;

(iii) End-stage lung disease;

(iv) Unstable diabetes or diabetes with complications;

(v) Uncontrolled hypertension or hypertension with complications;

(vi) Neoplasms or leukemia;

(vii) Organ transplantation;

(viii) Hereditary anemias;

(ix) Hemophilia or other congenital disorders of clotting factors;

(x) Acquired hemolytic anemias;

(xi) Aplastic anemias;

(xii) Deficiency of humoral immunity;

(xiii) Deficiency of cell-mediated immunity;

(xiv) Combined immunity deficiency;

(xv) Cystic fibrosis;

(xvi) Malabsorption;

(xvii) Failure to thrive;

(xviii) Infant prematurity;

(xix) Respiratory distress syndrome or other respiratory conditions of the fetus or newborn; or

(xx) The terminal stage of any life-threatening illness.

Replaces: 5160-4-06, 5160-4- 06.1

Cite as Ohio Admin. Code 5160-4-06

Effective: 6/1/2017
Five Year Review (FYR) Dates: 06/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 07/01/1980, 06/03/1983, 10/01/1983 (Emer), 12/29/1983, 01/01/1986, 05/09/1986, 10/01/1987, 06/16/1988, 01/13/1989 (Emer), 04/13/1989, 09/01/1989, 05/01/1990, 02/17/1991, 05/25/1991, 04/01/1992 (Emer), 07/01/1992, 12/31/1992 (Emer), 04/01/1993, 12/30/1993 (Emer), 03/31/1994, 12/30/1994 (Emer), 03/30/1995, 12/29/1995 (Emer), 03/21/1996, 07/01/1996, 12/31/1997 (Emer), 03/19/1998, 12/31/1998 (Emer), 03/31/1999, 03/20/2000, 03/20/2001, 12/31/2001 (Emer), 03/29/2002, 07/01/2003, 01/02/2004 (Emer), 04/01/2004, 12/30/2004 (Emer), 03/20/2005, 09/01/2005, 12/30/2005 (Emer), 03/27/2006, 12/29/2006 (Emer), 03/29/2007, 12/31/2007 (Emer), 03/30/2008, 10/25/2008, 12/31/2008 (Emer), 03/31/2009, 08/02/2011, 12/31/2012 (Emer), 03/28/2013, 09/01/2013

5160-4-06.1 [Rescinded] Physician attendance during patient transport.

Cite as Ohio Admin. Code 5160-4-06.1

Effective: 6/1/2017
Five Year Review (FYR) Dates: 03/03/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 12/31/2001 (Emer), 03/29/2002, 07/01/2003, 10/25/2008, 12/31/2008 (Emer), 03/31/2009, 08/02/2011

5160-4-08 [Rescinded] Covered obstetrical services.

Cite as Ohio Admin. Code 5160-4-08

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/14/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/08/1979, 02/01/1980, 05/09/1986, 04/01/1988, 09/01/1989, 05/01/1990, 02/14/1992 (Emer), 05/14/1992, 12/30/1993 (Emer), 03/31/1994, 03/30/1995, 12/29/1995 (Emer), 03/21/1996, 07/01/2003

5160-4-08.1 [Rescinded] Payment for prenatal visits.

Cite as Ohio Admin. Code 5160-4-08.1

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/14/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 10/01/2003, 07/01/2008

5160-4-09 [Rescinded] Office incentive program.

Cite as Ohio Admin. Code 5160-4-09

Effective: 12/31/2013
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 03/20/1984, 01/04/1988, 09/01/1989, 05/01/1990, 05/25/1991, 04/01/1992 (Emer), 07/01/1992, 12/31/1992 (Emer), 04/01/1993, 03/30/1995, 03/21/1996, 01/01/2001, 01/08/2004, 03/30/2008, 12/30/10 (Emer), 03/30/2011

5160-4-10 [Rescinded] Pregnancy related services.

Cite as Ohio Admin. Code 5160-4-10

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/14/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/01/1988, 05/15/1989, 02/14/1992, 01/01/2001, 07/01/2003

5160-4-11 Place-of-service restrictions for diagnostic and therapeutic procedures.

Place-of-service restrictions for covered diagnostic and therapeutic procedures are addressed in rule 5160-1-60 of the Administrative Code and are summarized in appendix DD to that rule.

Replaces: 5160-4-11

Cite as Ohio Admin. Code 5160-4-11

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 4/1/92 (Emer), 7/1/92, 12/31/92 (Emer), 4/1/93, 12/30/93 (Emer), 3/31/94, 5/2/94 (Emer), 7/1/94, 1/1/01, 8/2/11

5160-4-12 Immunizations, injections and infusions (including trigger-point injections), and provider-administered pharmaceuticals.

(A) General provisions.

(1) "Current procedural terminology (CPT)" is a comprehensive listing of medical terms and codes published by the American medical association, www.ama-assn.org, for the uniform designation of diagnostic and therapeutic procedures in surgery, medicine, and the medical specialties. "Healthcare common procedure coding system (HCPCS)" is a numeric and alphanumeric code set maintained and distributed by the centers for medicare and medicaid services (CMS), http://www.cms.gov, for the uniform designation of certain medical procedures and services.

(2) A "not otherwise specified," "unlisted," or "miscellaneous" procedure code should be reported on a claim only if no procedure code is available that identifies the particular service or item provided.

(3) No separate payment is made for an immunization, injection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provided in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department).

(4) A provider-administered pharmaceutical reported on a claim submitted in accordance with Chapter 5160-9 of the Administrative Code is regarded as a pharmacy service rather than a physician service, and payment of the claim is governed by the provisions of that chapter. For example, a vaccine, toxoid, or other provider-administered pharmaceutical prescribed for a resident of a long-term care facility (LTCF) and subsequently administered by a LTCF staff member is a pharmacy service.

(5) Payment for an immunization, injection, or infusion includes payment for related supplies (e.g., alcohol wipes, needles, syringes, and tubing).

(B) Coverage of immunizations. An immunization has two components: the administration of the vaccine or toxoid and the vaccine or toxoid itself.

(1) Payment for administration may take one of two forms:

(a) Payment for the most appropriate administration procedure; or

(b) Payment for the least complex evaluation and management service rendered to an established patient.

(2) Separate payment may be made for the vaccine or toxoid. No payment, however, will be made for vaccines that can be obtained at no cost through the federal vaccines for children (VFC) program, which is administered by the Ohio department of health (ODH).

(3) Limitations based on age or gender apply to certain vaccines.

(a) Regardless of the formulation, payment for hepatitis B vaccine (HBV) administered to individuals younger than nineteen years of age may be made only under the VFC program. Different procedure codes must be reported on claims to distinguish HBV administered to individuals younger than nineteen from HBV administered to individuals older than eighteen.

(b) Both the quadrivalent vaccine and the nine-valent vaccine for the human papilloma virus (HPV) are covered for both males and females from nine through twenty-one years of age. For both males and females who are eligible for medicaid only through the family planning services benefit, coverage extends through twenty-six years of age.

(c) The bivalent vaccine for HPV is covered for females from nine through twenty-one years of age. For females who are eligible for medicaid only through the family planning services benefit, coverage extends through twenty-six years of age. This vaccine is not covered for males.

(C) Coverage of therapeutic, prophylactic, or diagnostic injections or infusions (excluding chemotherapy and other complex procedures).

(1) An injection or infusion has two components: the administration of a fluid medium and, except in the case of hydration, the pharmaceutical itself. No separate payment is made for the administration service if an injection or infusion is given during the course of an office visit or in conjunction with another medical service that includes an evaluation and management element.

(2) Payment may be made for an injection or infusion or a provider-administered pharmaceutical only if at least one of the following criteria is met:

(a) Its use for a particular indication has been approved by the U.S. food and drug administration; or

(b) According to accepted standards of medical practice, it is a specific or effective treatment for the particular condition for which it is given.

(3) No separate payment is made for an injection or infusion or a provider-administered pharmaceutical that meets either of the following criteria:

(a) The frequency or duration of its administration exceeds accepted standards of medical practice for the particular condition; or

(b) It is provided for or in association with noncovered medicaid services, which are defined in rule 5160-4-28 of the Administrative Code.

(4) Immune globulin is covered when it is used to provide passive immunity to an individual who is immunosuppressed; has an acquired or congenital immunodeficiency; is at risk of Rho (D) isoimmunization; or is in immediate danger of contracting a communicable disease through direct contact with blood, saliva, or other body fluids through an open wound, bite, puncture, or mucous membrane.

(5) Epoetin alfa (EPO) for the treatment of anemia, either associated with or not related to chronic renal failure, is covered as a medical service when a provider incurs the cost of the drug and the service is provided in a clinic (e.g., a renal dialysis facility) or office setting.

(6) Certain procedure codes represent a specific number of dosage units. On a claim, the fewest number of procedure codes must be reported together to represent the administered dosage.

(D) Coverage of trigger-point injections.

(1) A trigger point is a hyperexcitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Payment may be made for a trigger-point injection only if the following criteria are met:

(a) The patient must have a diagnosis for which the trigger-point injection is an appropriate treatment; and

(b) The following information must be documented in the patient's medical record:

(i) A proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point;

(ii) The reason or reasons for selecting this therapeutic option;

(iii) The affected muscle or muscles;

(iv) The muscle or muscles injected and the number of injections;

(v) The frequency of injections required;

(vi) The name of the medication used in the injection;

(vii) The results of any prior treatment; and

(viii) Corroborating evidence that the injection is medically necessary.

(2) A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed.

(3) Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date.

(4) Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. For trigger-point injections of a local anesthetic or a steroid, payment will be made for no more than eight dates of service per calendar year per patient.

(E) Claim payment.

(1) On the department's web site, http://medicaid.ohio.gov, is a list of vaccines, toxoids, and other provider-administered pharmaceuticals each of which is covered by medicaid either as a medical service or as a VFC-designated vaccine. Payment for a covered non-VFC vaccine, toxoid, or other provider-administered pharmaceutical is the lesser of two figures:

(a) The provider's submitted charge; or

(b) The maximum allowable amount, which is the first applicable item from the following ordered list:

(i) An amount specified in or determined in accordance with the Administrative Code;

(ii) The maximum allowable cost (MAC), which is defined in Chapter 5160-9 of the Administrative Code;

(iii) The payment limit shown in the current medicare part B drug pricing file, which is available at http://www.cms.gov;

(iv) One hundred seven per cent of the wholesale acquisition cost (WAC); or

(v) Eighty-five and six-tenths per cent of the average wholesale price (AWP).

(2) The payment amount for any other covered administration service or evaluation and management service is the lesser of the provider's submitted charge or the maximum amount listed in appendix DD to rule 5160-1-60 of the Administrative Code.

Replaces: 5160-4-12

Cite as Ohio Admin. Code 5160-4-12

Effective: 11/1/2015
Five Year Review (FYR) Dates: 11/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/01/1977, 12/21/1977, 12/30/1977, 01/08/1979, 02/01/1980, 09/20/1984 (Emer), 12/17/1984, 05/19/1986, 07/01/1987, 04/01/1988, 09/01/1989, 05/25/1991, 03/19/1992, 12/01/1992, 12/30/1992 (Emer), 12/31/1992 (Emer), 04/01/1993, 12/30/1993 (Emer), 03/31/1994, 09/30/1994 (Emer), 12/30/1994 (Emer), 12/30/1994, 03/30/1995, 08/01/1995, 12/29/1995 (Emer), 03/21/1996, 12/31/1996 (Emer), 03/22/1997, 08/01/1997, 12/31/1997 (Emer), 03/19/1998, 12/31/1998 (Emer), 03/31/1999, 03/20/2000, 12/29/2000 (Emer), 01/01/2001, 03/30/2001, 01/01/2003, 04/14/2003, 01/02/2004 (Emer), 04/01/2004, 10/01/2004, 11/15/2004, 09/01/2005, 12/30/2005 (Emer), 03/27/2006, 07/01/2006, 07/15/2006, 01/01/2007, 07/25/2007, 12/31/2007 (Emer), 03/30/2008, 07/01/2008, 11/13/2008, 12/31/2008 (Emer), 03/31/2009, 07/01/2009, 10/01/2009 (Emer), 12/29/2009, 03/31/2010, 04/28/2010 (Emer), 07/26/2010, 12/30/2010 (Emer), 03/30/2011, 08/02/2011, 09/01/2011, 12/30/2011 (Emer), 03/29/2012, 12/31/2012 (Emer), 03/28/2013, 09/01/2013

5160-4-13 Relocated provisions concerning injections and provider-administered pharmaceuticals.

Provisions for coverage of and payment for injections and pharmaceuticals administered as physician services are set forth in rule 5160-4-12 of the Administrative Code.

Cite as Ohio Admin. Code 5160-4-13

Effective: 11/1/2015
Five Year Review (FYR) Dates: 07/17/2015 and 11/01/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/01/2013

5160-4-14 Dialysis services provided by medical practitioners.

(A) Routine maintenance dialysis.

(1) All practitioner professional services associated with the medical management of end-stage renal disease (ESRD) patients receiving maintenance dialysis are paid by the Ohio department of medicaid on a monthly capitation payment basis.

(2) Claims may be submitted for the following services in addition to the monthly capitation payment:

(a) The declotting of shunts; and

(b) Covered professional services that are unrelated to the patient's dialysis or renal condition.

(3) To receive the monthly capitation payment, the practitioner must submit a claim to the department on the last day of the month using the appropriate current procedural terminology (CPT) code.

(a) Several practitioners may form a team to provide the monthly continuity of services to a single patient or to a group of ESRD patients, or a practitioner in independent practice may make arrangements with an associate to provide the services to his/her ESRD patients when he/she is temporarily unavailable. Such arrangements are referred to as joint provisions . Under a joint provision, each practitioner may cover for another, and claims for the monthly capitation payment may be submitted by and paid to the primary practitioner. The primary practitioner must make arrangements to compensate the other practitioners involved in the dialysis care of the patient(s).

(b) When the dialysis care of a patient is provided by more than one practitioner during a calendar month and there is not a joint provision between the practitioners, the practitioners who provided the split services during the month must submit claims to the department separately using the appropriate daily dialysis care CPT code for each day the practitioner was responsible for the patient's care.

(c) For a recipient during a calendar month, the following payments should never be made:

(i) More than one monthly capitation payment ;

(ii) More than thirty-one days of daily dialysis care ; or

(iii) Payment for the monthly capitation payment and daily dialysis care. .

(4) If a dialysis patient is admitted to a hospital for no reason other than to receive maintenance dialysis (e.g., there was no space available in the dialysis unit or the patient was scheduled for extended intermittent peritoneal dialysis), payment for the professional services associated with the dialysis is still considered routine maintenance dialysis and may be paid only on a monthly capitation payment basis.

(B) Inpatient dialysis services.

(1) Except as provided for in paragraph (A)(4) of this rule, practitioners may be paid on a fee-for-service (procedure code) basis for professional services provided to hospital inpatients. To be eligible for payment on a fee-for-service basis, the practitioner must be present with the patient at some time during the dialysis, the patient's medical records must document that the practitioner was present, and the dialysis must be performed for one of the following reasons:

(a) For acute renal failure or renal trauma;

(b) As an initial course of dialysis (the "initial course of dialysis" means the first dialysis treatment and all subsequent dialysis treatments performed prior to the patient's stabilization on dialysis); or

(c) For an ESRD patient who was admitted to the hospital for a condition or illness unrelated to the patient's renal condition and the practitioner has elected to submit a claim for the inpatient dialysis services on a fee-for-service basis. If the practitioner has elected to submit a claim for the inpatient dialysis services on a fee-for-service basis and the practitioner usually is paid the monthly capitation payment, the practitioner may not

submit a claim for the monthly capitation payment that month and must instead submit a claim using the appropriate daily dialysis care CPT code only for the days when the patient was not a hospital inpatient.

(2) For payment for inpatient dialysis services on a fee-for-service basis, the provider must submit a claim with the appropriate inpatient dialysis care CPT code. .

(3) All evaluation and management services related to the patient's end stage renal disease that are rendered on a day when dialysis is performed and all other patient care services that are rendered during the dialysis procedure are included in the payment for hemodialysis and other dialysis care procedure codes.

Cite as Ohio Admin. Code 5160-4-14

Effective: 10/1/2016
Five Year Review (FYR) Dates: 06/23/2016 and 10/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/01/1989, 05/25/1991, 12/01/1992, 102/31/1992 (Emer), 04/01/1993, 12/29/1995 (Emer), 03/21/1996, 12/31/2008 (Emer), 03/31/2009

5160-4-16 [Rescinded] Cardiovascular diagnostic and therapeutic services.

Cite as Ohio Admin. Code 5160-4-16

Effective: 1/1/2017
Five Year Review (FYR) Dates: 09/19/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 9/1/89, 5/1/90, 2/17/91, 4/1/92 (Emer), 7/1/92, 12/30/93 (Emer), 3/31/94, 5/2/94 (Emer), 7/1/94, 12/30/94 (Emer), 3/30/95, 12/31/96 (Emer), 3/22/97, 1/1/01, 12/31/01 (Emer), 3/29/02, 10/1/06

5160-4-17 [Rescinded] Gastroenterology, otorhinolaryngology, endocrinology, neurology, photodynamic therapy and special dermatology services.

Cite as Ohio Admin. Code 5160-4-17

Effective: 1/1/2017
Five Year Review (FYR) Dates: 09/19/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 9/1/89, 5/25/91, 4/1/92 (Emer), 7/1/92, 12/30/93 (Emer), 3/31/94, 12/30/94 (Emer), 3/30/95, 12/29/95 (Emer), 3/21/96, 12/31/01 (Emer), 3/29/02, 7/1/03, 1/2/04 (Emer), 4/1/04, 12/30/04 (Emer), 3/20/05, 12/30/05 (Emer), 3/27/06, 12/29/06 (Emer), 3/29/07, 12/31/07 (Emer), 3/30/08, 12/31/08 (Emer), 3/31/09

5160-4-18 [Rescinded] Pulmonary services.

Cite as Ohio Admin. Code 5160-4-18

Effective: 1/1/2017
Five Year Review (FYR) Dates: 09/19/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 9/1/89, 5/25/91, 4/1/92 (Emer), 7/1/92, 12/30/94 (Emer), 3/20/95, 1/1/01, 10/1/04, 12/29/06 (Emer), 3/29/07

5160-4-19 Allergy services.

(A) Purpose. This rule addresses payment for the professional administration and evaluation of allergy sensitivity test procedures, which can be divided into three categories: allergy testing, ingestion challenge testing, and allergen immunotherapy. Payment for related laboratory tests is addressed in Chapter 5160-11 of the Administrative Code.

(B) Coverage.

(1) Allergy testing.

(a) There must be a reasonable probability, documented in the individual's medical file, that the individual was exposed to the antigen being used for the test.

(b) The unit of service is the test. Payment may be made only for the fewest number of tests necessary to reach a diagnosis.

(c) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(d) A qualitative multiallergen screen for allergen-specific immunoglobulin E (IgE) is not considered to be medically necessary.

(2) Ingestion challenge testing.

(a) The unit of service is the encounter. Payment may be made only once per visit regardless of the number of items tested.

(b) Payment includes the evaluation of the individual's response to the test items.

(3) Allergen immunotherapy.

(a) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(b) Payment for the antigen is made separately. No payment will be made for a service that includes administration (injection) as well as the antigen and its preparation.

(c) The unit of service is the dose-per-vial.

(d) Separate payment for the preparation of a single-dose vial of allergen antigen may be made only if the provider prepares the antigen for injection by another entity.

(e) The date of service is the date on which the first dose is administered or the date on which the vial is dispensed for future use.

(f) Immunotherapy is not considered to be medically necessary for the following antigens: newsprint, tobacco smoke, orris root, phenol, formalin, alcohol, sugar, yeast, grain mill dust, goldenrod, pyrethrum, marigold, soybean dust, honeysuckle, wool, fiberglass, green tea, and chalk.

Replaces: 5160-4-19

Cite as Ohio Admin. Code 5160-4-19

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/01/1989, 04/01/1992 (Emer), 07/01/1992, 04/01/1993, 12/30/1993 (Emer), 03/03/1994, 12/30/1994 (Emer), 03/20/1995, 01/01/2001, 09/01/2005, 08/02/2011, 12/31/2012 (Emer), 03/28/2013

5160-4-20 Chemotherapy treatment.

(A) Provision of the chemotherapeutic agent.

When the chemotherapeutic agent is provided through the physician's office, physician's group practice, or clinic and is administered in a nonhospital setting, the physician may be reimbursed for the cost of the chemotherapeutic agent by billing the appropriate healthcare common procedure coding system (HCPCS) injection code.

(B) Reimbursement for chemotherapy administration is restricted to certain place of service settings as set forth in rule 5160-1-60 of the Administrative Code.

(1) The administration of chemotherapy includes the preparation of the chemotherapeutic agent and all therapeutic services and medical supplies provided during treatment.

(2) When chemotherapy is administered in the physician's office, group practice, or clinic, the physician may be reimbursed for chemotherapy treatments personally administered by the billing physician or by a qualified employee supervised by the billing physician. For reimbursement, the provider must bill the appropriate current procedural terminology (CPT) code for chemotherapy.

(3) The administration of chemotherapy is independent of the physician's professional service and the office visit. When a physician examines the patient, a visit may be billed in conjunction with the chemotherapy injection and administration codes (nonhospital setting only). The professional services involved in the supervision and monitoring of the chemotherapy treatments are considered a part of the evaluation and management (visit) service.

Cite as Ohio Admin. Code 5160-4-20

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/11/2016 and 12/31/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.02
Prior Effective Dates: 9/1/89, 5/1/90, 4/1/92 (Emer), 7/1/92, 3/30/95, 8/2/2011

5160-4-21 Anesthesia services.

(A) Scope and definitions.

(1) This rule sets forth provisions governing payment for the administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners. Provisions governing payment for anesthesia as a dental service are set forth in Chapter 5160-5 of the Administrative Code.

(2) "Base unit" is an anesthesia-related component representing factors other than an anesthetist's time, such as standard pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia administration, and monitoring.

(3) "Base unit value" is the initial value for a base unit assigned by the American society of anesthesiologists. The society publishes base unit values in its "Relative Value Guide," available at http://www.asahq.org.

(4) "Time unit" is an anesthesia-related component representing the span, reported in minutes, during which an anesthesiologist or a medically-directed or medically-supervised qualified non-physician anesthetist is continuously present. The measured length of the time unit depends on the type of anesthesia.

(a) For neuraxial labor analgesia, the time unit begins when the analgesic is inserted and ends at delivery. Total duration is limited to two hundred forty minutes (four hours).

(b) For all other anesthesia, the time unit begins when the anesthetist starts to prepare the individual for the induction of anesthesia and ends when the presence of the anesthetist is no longer required and the individual may be safely placed under post-anesthetic care.

(5) "Time unit value" is the number of fifteen-minute increments in a time unit, rounded to the nearest tenth.

(B) Providers.

(1) Rendering providers. The following eligible medicaid providers may administer anesthesia:

(a) An anesthesiologist (i.e., a physician trained in anesthesia);

(b) A certified registered nurse anesthetist (CRNA); or

(c) An anesthesiologist assistant (AA).

(2) Billing providers. The following eligible medicaid providers may receive medicaid payment for submitting a claim for administering anesthesia:

(a) An anesthesiologist;

(b) A CRNA;

(c) A professional medical group; or

(d) An AA.

(C) Coverage.

(1) Payment may be made for the following procedures or activities as anesthesia services:

(a) Procedures performed during a surgical or diagnostic procedure:

(i) Administration of general anesthesia;

(ii) Administration of regional anesthesia;

(iii) Supplementation of local anesthesia;

(iv) Administration of post-operative pain block procedures separately from anesthesia;

(v) Provision of monitored anesthesia care (MAC); and

(vi) Performance of unusual monitoring procedures such as cardiovascular catheterization (e.g., intra-arterial, central venous, Swan-Ganz);

(b) Administration of obstetrical anesthesia for either of two purposes:

(i) Neuraxial analgesia for vaginal delivery (including repeated subarachnoid needle placement, drug injection, and necessary epidural catheter replacement during labor); or

(ii) Anesthesia for cesarean delivery; and

(c) Provision of medical direction or supervision by an anesthesiologist.

(2) No separate payment is made for the following services, which are considered to be part of anesthesia administration:

(a) Routine pre-operative and post-operative visits;

(b) Anesthesia care during the procedure;

(c) The administration of fluid or blood products incident to the anesthesia or surgery; and

(d) Usual monitoring procedures (e.g., electrocardiography, the taking of body temperature, the recording of blood pressure, oximetry, capnography, mass spectometry).

(D) Allowances and limitations.

(1) Payment may be made on a case-by-case basis for two anesthesia services provided to one individual on a single date of service only if at least one of the following conditions applies:

(a) Between the two surgical or diagnostic procedures, the individual either was released from the recovery area to the floor (or intensive care unit) or was discharged from the hospital;

(b) After completion of the surgical or diagnostic procedure, the individual had to return for a follow-up procedure on an emergency basis;

(c) It was medically necessary for two surgical or diagnostic procedures to be performed separately, and two separate anesthetics were required; or

(d) Anesthesia was administered both for a delivery and separately for a tubal ligation meeting the requirements specified in Chapter 5160-21 of the Administrative Code.

(2) In all other cases, payment may be made only for one anesthesia service provided to one individual on a single date of service.

(3) Payment for anesthesia services may be made to an anesthesiologist only if all of the following conditions are met:

(a) The anesthesiologist acts exclusively as an anesthetist and does not also act as a surgeon or assistant surgeon;

(b) The anesthesiologist completes the following tasks in preparation for anesthesia administration:

(i) Performing a pre-anesthetic examination and evaluation or, for obstetrical anesthesia, performing or approving a pre-anesthetic examination and evaluation for labor analgesia provided by a qualified anesthetist; and

(ii) Prescribing an anesthesia plan or, for obstetrical anesthesia, prescribing or approving an anesthesia plan.

(c) For each individual patient, the anesthesiologist carries out the following activities:

(i) Personally participating in the most demanding parts of the anesthesia plan, including induction and emergence or, for obstetrical anesthesia, personally participating in all critical portions of the procedure (e.g., needle placement for neuraxial analgesia);

(ii) Ensuring that any procedures in the anesthesia plan that the anesthesiologist does not perform are performed by a qualified individual;

(iii) Monitoring the course of anesthesia administration at frequent intervals or, for obstetrical anesthesia, periodically monitoring the course of anesthesia or analgesia administration or ensuring that a qualified anesthetist performs the monitoring;

(iv) Remaining physically present and available for immediate diagnosis and treatment in case of emergency or, for obstetrical anesthesia, remaining readily available for immediate diagnosis and treatment in case of emergency; and

(v) Providing indicated post-anesthetic care.

(4) Payment for medical direction may be made to an anesthesiologist if the anesthesiologist delegates some or all of the activities listed in paragraphs (D)(3)(b) and (D)(3)(c) of this rule to not more than four qualified non-physician anesthetists performing concurrent anesthesia procedures.

(5) Payment for medical supervision may be made to an anesthesiologist if the following conditions are met:

(a) For obstetrical anesthesia, the anesthesiologist delegates some or all of the activities listed in paragraph (D)(3)(c) of this rule to qualified non-physician anesthetists, and the anesthesiologist supervises one of the following activities:

(i) A critical portion of more than four concurrent obstetrical anesthesia procedures (e.g., needle placement for neuraxial analgesia);

(ii) A critical portion of an obstetrical anesthesia procedure along with more than four concurrent surgical anesthesia procedures; or

(iii) A critical portion of an obstetrical anesthesia procedure while the anesthesiologist is not physically present in the obstetrical suite.

(b) For all other anesthesia, the anesthesiologist delegates some or all of the activities listed in paragraph (D)(3)(c) of this rule to more than four qualified non-physician anesthetists performing concurrent anesthesia procedures.

(6) In addition to payment for surgical procedures, a surgeon or a group practice of surgeons is permitted to receive payment for anesthesia services provided by a CRNA who is employed by the surgeon or group practice.

(7) The services of a CRNA or AA employed by a hospital are considered to be hospital services, payment for which is made to the hospital.

(E) Claim payment.

(1) Payment for an anesthesia service is the lesser of the provider's submitted charge or the medicaid maximum, which is determined by a formula.

(a) The amount is the product of three factors:

(i) The sum of the base unit value and the time unit value;

(ii) The appropriate conversion factor; and

(iii) The relevant multiplier.

(b) Conversion factors and multipliers are listed in the appendix to this rule.

(c) For daily management of epidural or subarachnoid drug administration, the time unit value is zero.

(2) No additional payment will be made on account of physical status, age, body temperature (hypothermia or hyperthermia), emergency conditions, or time of day.

Replaces:

5160-4-21, 5160-4- 21.1, 5160-4- 21.2

Click to view Appendix

Cite as Ohio Admin. Code 5160-4-21

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 06/03/1983, 10/01/1983 (Emer), 12/29/1983, 01/01/1986, 05/09/1986, 06/16/1988, 01/13/1989 (Emer), 04/13/1989, 09/01/1989, 05/02/1994 (Emer), 06/03/1994 (Emer), 07/24/1994, 03/30/1995, 12/31/1996 (Emer), 03/22/1997, 01/01/2000, 05/01/2001, 01/01/2002, 09/01/2002, 09/01/2005, 10/01/2006, 11/20/2007, 01/01/2010

5160-4-21.1 [Rescinded] Anesthesia for neuraxial analgesia for obstetrical services.

Cite as Ohio Admin. Code 5160-4-21.1

Effective: 1/1/2017
Five Year Review (FYR) Dates: 04/29/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 1/01/02, 10/1/06

5160-4-21.2 [Rescinded] Anesthesia conversion factors.

Cite as Ohio Admin. Code 5160-4-21.2

Effective: 1/1/2017
Five Year Review (FYR) Dates: 04/29/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 9/1/02, 9/1/05, 1/1/2010

5160-4-22 Surgical services.

(A) Coverage.

(1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on an eligible recipient. The following limitations, however, apply.

(a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any procedure that is performed incidental to or as an integral part of the operation. On claims, providers should report comprehensive surgical services; they must not itemize or "unbundle" individual components.

(b) Certain characteristics of a surgical procedure performed on the same patient by the same provider may affect how it is reported on a claim and how payment for it is made.

(i) The department recognizes five groups of surgical procedures defined by a particular characteristic:

(a) Multiple procedures, for which payment is reduced when more than one is performed;

(b) Bilateral procedures, for which payment is adjusted when they are performed on both body parts of a corresponding pair;

(c) Co-surgery procedures, for which payment is split among two surgeons when performed. Co-surgery refers to a single surgical procedure which requires the skill of two surgeons, each in a different specialty, performing parts of the same procedure simultaneously.

(d) Assistant-at-surgery procedures, for which payment is reduced when they are performed by an assistant at surgery; and

(e) Procedures performed on fingers, toes, eyelids, or coronary arteries.

(ii) In assigning covered procedures to these groups, the department follows the policies of the medicare program except when otherwise noted in this rule.

(2) The following constraints apply to payment for co-surgery procedures:

(a) The procedure can be performed only by surgeons;

(b) No more than two surgeons can submit a claim for a co-surgery procedure; and

(c) The department covers co-surgery procedures that may be submitted directly, meaning the procedure does not require manual review of supporting documentation to establish that two surgeons are necessary.

(3) The following constraints apply to payment for assistant-at-surgery procedures:

(a) No payment is made for more than one assistant at surgery, regardless of the extent of the surgery;

(b) Payment may be made for an assistant at surgery in a teaching hospital only if any of the following conditions is met:

(i) The service performed is medically necessary, the physician who performs it is primarily engaged in the field of surgery, and the primary surgeon does not use residents or interns for any part of the surgical procedure (including preoperative and postoperative care);

(ii) The service constitutes concurrent care for a medical condition that requires the presence of and active treatment by a physician of another specialty during surgery;

(iii) Complex medical procedures are performed that require a team of physicians; or

(iv) Exceptional medical circumstances warrant an assistant at surgery; and

(c) No payment is made for an assistant at surgery in a teaching hospital if the following two conditions are met:

(i) The hospital has a training program in the medical specialty required for the surgical procedure; and

(ii) A resident in that training program is available to serve as an assistant at surgery.

(4) Payment for physician visits in addition to surgery is addressed in rule 5160-4-06 of the Administrative Code.

(5) Certain types of surgery are often supplemented by the use of a cast, splint, strap, or other traction device. For initial application and removal that is performed in conjunction with covered musculoskeletal surgery, payment for the surgery includes the application and removal procedures, all materials (casting components, splints, or straps), and incidental supplies. In all other circumstances, the following provisions apply:

(a) Payment for the work depends on the nature and purpose of the procedure.

(i) For initial application and removal that is not performed in conjunction with surgery (e.g., the casting or strapping of a sprained joint), payment may be made for an appropriate evaluation and management service;

(ii) For necessary replacement, payment may be made for an appropriate casting/strapping procedure; and

(iii) For necessary repair, payment may be made for an appropriate evaluation and management service.

(b) Separate payment may be made for materials only if the service was rendered in a non-hospital setting.

(c) No separate payment is made for incidental supplies.

(B) Claim payment. Payment for a surgical procedure is the lesser of two figures:

(1) The provider's submitted charge; or

(2) A percentage of the medicaid maximum amount specified in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule, determined in the following manner:

(a) For a procedure that is not performed incidental to or as an integral part of an operation and that is not subject to multiple-procedure payment reduction, one hundred per cent;

(b) For a procedure that is subject to multiple-procedure payment reduction, the relevant percentage from the following list:

(i) For a primary procedure (i.e., the procedure with the highest maximum amount listed in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule), one hundred per cent;

(ii) For a secondary procedure (i.e., the procedure with the next highest maximum amount listed in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule), fifty per cent; or

(iii) For any other procedure, twenty-five per cent;

(c) For a co-surgery procedure, sixty two and a half percent per surgeon;

(d) For a bilateral procedure, one hundred fifty per cent; or

(e) For an assistant-at-surgery procedure, twenty-five per cent.

Cite as Ohio Admin. Code 5160-4-22

Effective: 7/1/2017
Five Year Review (FYR) Dates: 04/14/2017 and 07/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 4/1/1977, 12/21/1977, 12/30/1977, 1/8/1979, 2/1/1980, 9/20/1984 (Emer), 12/17/1984, 5/19/1986, 7/1/1987, 4/1/1988, 9/1/1989, 5/25/1991, 3/19/1992, 12/1/1992, 12/30/1992 (Emer), 12/31/1992 (Emer), 4/1/1993, 12/30/1993 (Emer), 3/31/1994, 9/30/1994 (Emer), 12/30/1994 (Emer), 12/30/1994, 3/30/1995, 8/1/1995, 12/29/1995 (Emer), 3/21/1996, 12/31/1996 (Emer), 3/22/1997, 8/1/1997, 12/31/1997 (Emer), 3/19/1998, 12/31/1998 (Emer), 3/31/1999, 3/20/2000, 12/29/2000 (Emer), 1/1/2001, 3/30/2001, 1/1/2003, 4/14/2003, 1/2/2004 (Emer), 4/1/2004, 10/1/2004, 11/15/2004, 9/1/2005, 12/30/2005 (Emer), 3/27/2006, 7/1/2006, 7/15/2006, 1/1/2007, 7/25/2007, 12/31/2007 (Emer), 3/30/2008, 7/1/2008, 11/13/2008, 12/31/2008 (Emer), 3/31/2009, 7/1/2009, 10/1/2009 (Emer), 12/29/2009, 3/31/2010, 4/28/2010 (Emer), 7/26/2010, 12/30/2010 (Emer), 3/30/2011, 8/2/2011, 9/1/2011, 12/30/2011 (Emer), 3/29/2012, 12/31/2012 (Emer), 3/28/2013, 12/18/13 (Emer), 3/27/14, 12/31/14 (Emer), 7/3/2015

5160-4-23 Covered ambulatory surgery center (ASC) surgical procedures.

(A) Payment may be made to an ambulatory surgery center (ASC) in the form of a facility fee only for covered ASC surgical procedures, which are procedures that meet the standards set forth in 42 CFR 416.65(a) and 416.65(b) (October 1, 2014). Such procedures are identified in appendix DD to rule 5160-1-60 of the Administrative Code.

(B) Payment may be made to a physician for performing a covered surgical procedure in an ASC even if the surgery is not itself a covered ASC surgical procedure.

(C) Payment may be made to a physician for performing the professional component of a covered laboratory, radiologic, diagnostic, or therapeutic service in an ASC only if the physician personally performed the service and was not an employee of the ASC at the time.

Replaces: 5160-4-23

Cite as Ohio Admin. Code 5160-4-23

Effective: 7/9/2015
Five Year Review (FYR) Dates: 07/09/2020
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 09/01/1989, 12/29/1995 (Emer), 03/21/1996, 01/01/2001, 07/01/2009

5160-4-25 Radiology and imaging services.

(A) Coverage.

(1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met:

(a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and

(b) The practitioner who submitted the claim either performed the professional component or has an employment or written contractual arrangement with the practitioner who performed the professional component.

(2) Technical component. Payment may be made to a practitioner for performing only the technical component of a radiology or imaging procedure if three conditions are met:

(a) The professional component was performed by another practitioner;

(b) The technical component was not performed in a hospital setting; and

(c) The practitioner who submitted the claim either performed the technical component or employs the practitioner who performed the technical component.

(3) Professional component.

(a) Payment may be made to a practitioner for performing only the professional component of a radiology or imaging procedure if the professional component represents either of two services:

(i) The initial interpretation of a radiology or imaging procedure; or

(ii) The interpretation by a specialist of a radiology or imaging procedure that has already been interpreted by another practitioner (e.g., a treating physician).

(b) No payment is made for the interpretation by a non-specialist of a radiology or imaging procedure that has already been interpreted by a specialist.

(4) Mammography services.

(a) Payment for screening mammography may be made at the following frequencies:

(i) For an individual who is at least thirty-five years of age but less than forty, once; and

(ii) For an individual who is at least forty years of age, once per twelve months.

(b) Payment for diagnostic mammography may be made for an individual, regardless of age, who shows clinical symptoms of breast cancer or who is at high risk for developing breast cancer.

(5) No separate payment is made for supplies used in connection with a radiology or imaging procedure performed in a hospital setting.

(6) No separate payment is made for conscious sedation administered in connection with a radiology or imaging procedure.

(B) Claim payment.

(1) For a covered radiology or imaging procedure or radiology or imaging procedure component performed by a non-hospital provider, payment is the lesser of the submitted charge or the product of the following two figures:

(a) The maximum payment amount listed in appendix DD to rule 5160-1-60 of the Administrative Code; and

(b) The relevant percentage indicated by the 'prof/tech split' entry listed in appendix DD to rule 5160-1-60 of the Administrative Code.

(2) If more than one advanced imaging procedure (e.g., computed tomography, magnetic resonance imaging, ultrasound) is performed by the same provider or provider group for an individual patient in the same session, then the procedure with the highest payment amount specified in appendix DD to rule 5160-1-60 of the Administrative Code is considered to be the primary procedure. The payment amount for a covered advanced imaging procedure is the lesser of the submitted charge or a percentage of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code, determined in the following manner:

(a) For a primary procedure, it is one hundred per cent.

(b) For each additional total procedure, it is fifty per cent.

(c) For the technical component alone of each additional procedure, it is fifty per cent.

(d) For the professional component alone of each additional procedure, it is ninety-five per cent.

Replaces: 5160-4-25

Cite as Ohio Admin. Code 5160-4-25

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/01/2022
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 06/03/1983, 10/01/1983 (Emer), 12/29/1983, 01/01/1986, 05/09/1986, 06/16/1988, 01/13/1989, (Emer), 04/13/1989, 09/01/1989, 05/01/1990, 02/17/1991, 05/25/1991, 12/30/1993 (Emer), 03/31/1994, 05/02/1994 (Emer), 07/01/1994, 12/30/1994 (Emer), 03/30/1995, 03/21/1996, 07/01/1996, 12/31/1997 (Emer), 03/19/1998, 12/31/1998 (Emer), 03/31/1999, 01/01/2001, 07/01/2003, 09/01/2005, 12/30/2005 (Emer), 03/27/2006, 08/02/2011, 12/31/2013, 07/31/2014

5160-4-26 Physical medicine and rehabilitation services.

(A) Payment may be made for covered physical medicine and rehabilitation services performed by a physician or by a licensed individual under the direct supervision of a physician in accordance with rule 5160-4-02 of the Administrative Code.

(B) Physical therapy, occupational therapy, speech-language pathology, and audiology are addressed in Chapter 5160-8 of the Administrative Code.

Replaces: Part of 5160-4-26

Cite as Ohio Admin. Code 5160-4-26

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 10/01/1983 (Emer), 12/29/1983, 01/01/1986, 05/04/1986, 06/16/1988, 01/13/1989 (Emer), 09/01/1989, 12/30/1994 (Emer), 03/30/1995, 07/01/2002, 01/01/2008

5160-4-27 Physician reimbursement of medical supplies and durable medical equipment.

(A) Medical supplies and durable medical equipment are items and equipment as defined in rule 5101:3-10-02 of the Administrative Code.

(B) A physician may not be separately reimbursed for medical supplies or durable medical equipment utilized in a physician's office, clinic, or patient's home during a physician's visit.

(C) A physician may be reimbursed for medical supplies or durable medical equipment dispensed in the physician's office, clinic, or patient's home, for use in the patient's home, if the physician has a "supplies and medical equipment" category of service.

(D) All physician's who have a valid "medicaid provider agreement" are eligible to apply for and receive a "supplies and medical equipment" category of service.

(E) Scope and extent of coverage.

(1) The scope and extent of coverage of medical supplies or durable medical equipment services are detailed in Chapter 5101:3-10 of the Administrative Code.

(2) All medical supplies or durable medical equipment require a written prescription by a physician, which must be kept on file for six years in the physician's office in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(F) Reimbursement.

All claims for medical supplies or durable medical equipment must be billed in accordance with rule 5101:3-10-05 of the Administrative Code.

Replaces: Former 5101:3-4-27

Cite as Ohio Admin. Code 5160-4-27

Effective: 11/20/2007
R.C. 119.032 review dates: 11/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 5/19/86, 7/1/87, 4/1/88, 9/1/89

5160-4-28 Relocated provisions concerning non-covered services.

Policy provisions concerning services for which medicaid makes no payment are set forth in rule 5160-1-61 of the Administrative Code.

Cite as Ohio Admin. Code 5160-4-28

Effective: 7/1/2016
Five Year Review (FYR) Dates: 07/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02

5160-4-29 [Rescinded] Services provided for the diagnosis and treatment of mental and emotional disorders.

Cite as Ohio Admin. Code 5160-4-29

Effective: 2/1/2016
Five Year Review (FYR) Dates: 10/28/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 02/17/1991, 11/01/2001, 10/01/2003, 12/31/2012 (Emer), 03/28/2013

5160-4-31 [Rescinded] Coverage of extra-corporeal-membrane-oxygenator (ECMO) services.

Cite as Ohio Admin. Code 5160-4-31

Effective: 9/1/2017
Five Year Review (FYR) Dates: 06/05/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 5/25/91, 4/1/92 (Emer), 7/1/92, 3/31/94, 1/1/01

5160-4-33 Application of topical fluoride varnish by non-dentist providers.

(A) Payment may be made not more frequently than once per one hundred eighty days to a physician, physician assistant, or advanced practice registered nurse for the topical application of fluoride varnish to the teeth of a child younger than six years of age.

(B) As part of the application of fluoride varnish, a practitioner must provide three related services:

(1) An oral assessment for the identification of obvious oral health problems and risk factors, which may be omitted if an oral assessment is conducted or has been conducted during an early and periodic screening, diagnosis, and treatment (EPSDT) visit;

(2) Communication with the parent or guardian about the fluoride varnish procedure and proper oral health care for the child; and

(3) If the child has obvious oral health problems and does not have a dental provider, referral to a dentist or to the county department of job and family services.

(C) The application of fluoride varnish during a well child visit or a sick child visit should not be the sole reason for the visit.

Replaces: 5160-4-33

Cite as Ohio Admin. Code 5160-4-33

Effective: 1/1/2016
Five Year Review (FYR) Dates: 01/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 07/01/2006, 12/31/2012 (Emer), 03/28/2013

5160-4-34 [Rescinded] Preventive medicine services.

Cite as Ohio Admin. Code 5160-4-34

Effective: 10/1/2017
Five Year Review (FYR) Dates: 6/9/2017
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 07/01/1980, 10/01/1987, 09/01/1989, 04/01/1992 (Emer), 07/01/1992, 07/01/1993, 01/04/2000 (Emer), 03/20/2000, 12/31/2001 (Emer), 03/09/2002, 12/30/2005 (Emer), 03/27/2006, 11/13/2006, 07/01/2009, 12/22/2011

5160-4-35 Skin substitutes for wound treatment and healing.

(A) The following skin substitutes are covered in an office setting in conjunction with standard wound care regimens for the treatment of burns or ulcers:

(1) Q4101, skin substitute, apligraf, per square centimeter; and

(2) Q4102, skin substitute, oasis wound matrix, per square centimeter; and

(3) Q4103, skin substitute, oasis burn matrix, per square centimeter; and

(4) Q4106, skin substitute dermagraft, per square centimeter; and

(5) Q4110, skin substitute, primatrix, per square centimeter.

(B) Skin substitutes may be used on burns when skin grafting is not the appropriate option. These covered bioengineered skin substitutes are expected to function as a permanent replacement for lost or damaged skin. They may be used for temporary wound coverage or wound closure as appropriate and medically necessary.

(C) Skin substitutes are not separately reimbursable in any institutional setting, including long-term care facility, hospital inpatient, outpatient, or emergency room place of service.

(D) If skin substitute applications and re-applications show no significant improvement after three separate treatments, additional re-applications are inappropriate and other treatment modalities should be considered. Skin substitute treatments should not last more than twelve weeks. Improvement of fifty per cent or greater must be documented in the medical records for the reimbursement of additional re-applications after twelve weeks of treatment. If after twelve weeks the medical records do not support the significant improvement of the wound using the skin substitute treatments, the Ohio department of job and family services may recoup any inappropriate reimbursement.

(E) Wound preparation is considered part of the procedure. All products, including dressings, are included in the evaluation and management service and are not separately reimbursable.

Cite as Ohio Admin. Code 5160-4-35

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02

5160-4-36 Covered freestanding birth center (FBC) procedures.

(A) A physician may be reimbursed for all covered procedures performed in a freestanding birth center (FBC), as defined in rule 5101:3-18-01 of the Administrative Code.

(B) A physician may be reimbursed for the professional component of a covered laboratory, radiology, diagnostic, or therapeutic service only if the physician personally performed the service in the FBC and the service was not performed by an employee of the FBC.

Cite as Ohio Admin. Code 5160-4-36

Effective: 01/01/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02 , 5111.021