Chapter 5160-4 Physician Services

5160-4-01 Physicians and other eligible providers of physician services.

(A) The following definitions and clarifications apply to division 5101:3 of the Administrative Code:

(1) "Physician" is an individual currently licensed under the laws of Ohio or of another state to practice as a doctor of medicine and surgery or as a doctor of osteopathic medicine and surgery. An unlicensed individual who is authorized to practice under the laws of the state in which the services are performed is not a physician, even if the person holds a staff or faculty appointment.

(2) "Provider-based physician" is a physician who has entered into an employment agreement, contract, or other legally binding arrangement with a site-based provider entity such as a hospital, clinic (either fee-for-service or cost-based), or long-term care facility and is consequently under the fiscal, administrative, and professional control of that provider entity. Interns, residents, and fellows are not physicians. Services provided by interns, residents, and fellows are treated as hospital services.

(3) Physicians may form or enter into a professional medical group in accordance with the provisions set forth in rule 5101:3-1-17 of the Administrative Code. A professional medical group may submit claims for physician services performed by its member physicians.

(B) The following Ohio medicaid providers are eligible providers of physician services:

(1) A physician;

(2) A professional medical group;

(3) An ambulatory health care clinic, which is defined in Chapter 5101:3-13 of the Administrative Code;

(4) A federally qualified health center, which is defined in Chapter 5101:3-28 of the Administrative Code;

(5) An outpatient health facility, which is defined in Chapter 5101:3-29 of the Administrative Code;

(6) A rural health clinic, which is defined in Chapter 5101:3-16 of the Administrative Code; and,

(7) 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 ) and the regulations published at 42 C.F.R. Part 495 (July 28, 2010), an optometrist operating within the appropriate scope of practice defined in section 4725.01 of the Revised Code.

(C) Reimbursement for providers of physician services is subject to the following provisions:

(1) A provider of physician services may be reimbursed for providing covered services only if two conditions are met:

(a) The provider of physician services is currently enrolled as a medicaid provider; and

(b) The services are rendered to medicaid-eligible Ohio recipients in a state in which the provider is licensed or authorized to practice.

(2) Professional services rendered by a provider-based physician directly to or for the benefit of an individual patient are separately reimbursable only if the following requirements are met:

(a) The physician is separately enrolled as an Ohio medicaid provider;

(b) The physician personally rendered the services to the individual patient;

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

(d) The services ordinarily require performance by a physician;

(e) In the case of anesthesiology, laboratory, or radiology services, the additional requirements set forth in rules 5101:3-4-21 and 5101:3-4-25 of the Administrative Code are met; and

(f) The expenses associated with the provision of the professional services are excluded from the cost report of the site-based provider entity.

(3) Facility-related services rendered by a provider-based physician 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) are reimbursable only to the employing or contracting provider.

Replaces: 5101:3-4-01

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Effective: 03/02/2012
R.C. 119.032 review dates: 01/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
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)

5160-4-02 Scope of coverage.

(A) Definitions.

(1) "Direct supervision" in the physician's office, group practice, or clinic setting means that the physician must be present in the office suite throughout the time the non-physician is providing the service and immediately available to provide assistance and direction throughout the time the non-physician is performing services. Direct supervision does not mean the physician must be in the same room while the non-physician is providing services. The availability of the physician by telephone or the presence of the physician somewhere in the institution does not constitute direct supervision.

(2) "General supervision" means that the physician is available, but not necessarily present in the office suite or clinic, to provide those medical services which constitute the practice of medicine and surgery as defined under section 4731.34 of the Revised Code. However, if the physician is not physically present in the office suite he/she must be immediately available to the non-physician for consultation purposes by telephone and within a thirty-mile radius of the office.

(3) "Non-physician" means, for the purposes of this rule, an individual who is not licensed to practice medicine but who is licensed, credentialed, trained, or otherwise qualified and legally allowed to perform designated physician services.

(B) When services are provided by non-physicians, the services rendered must be within the non-physician's scope of licensure (if licensure is required) or a service for which the non-physician is legally authorized to provide under Ohio law and documented in the patient's medical records. Services provided by non-physicians may not be the type of services which constitute the practice of medicine and surgery as defined under section 4731.34 of the Revised Code.

(C) Services performed under direct supervision

(1) The department will reimburse an eligible provider of physician services for covered physician services personally provided by the physician or by a non-physician under the direct supervision of the physician unless otherwise stated in other rules in Chapter 5101:3-4 of the Administrative Code.

(2) Services provided under direct supervision are covered only if the following conditions are met:

(a) The non-physician personnel involved in performing the service must meet the following requirements:

(i) The non-physician must be a part-time, full-time or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician or the non-physician must be an independent contractor engaged by the physician through a written agreement; and

(ii) If the nonphysiciannon-physician is a leased employee or independent contractor, the physician or legal entity exercises control over the actions taken by the non-physician personnel with regard to the rendering of medical services to the same extent as the physician would exercise if the leased employee or contractor was an employee of the physician or legal entity.

(b) The service must represent an expense to the physician or legal entity;

(c) The physician must provide direct, personal supervision of the service as defined in paragraph (A) of this rule;

(d) The service must be furnished in connection with a covered physician service which was billed to the department. Therefore, the patient must be one who has been seen by the physician; and

(e) There must have been a personal professional service furnished by the physician to initiate the course of treatment on which the service being performed is an incidental part. In addition, there must be subsequent services by the physician of a frequency that reflects his/her continuing participation in the management of the course of treatment.

(D) Services performed under general supervision

(1) Services provided under general supervision are covered only if the following conditions are met:

(a) The non-physician personnel involved in performing the service must meet the following requirements:

(i) The non-physician must be a part-time, full-time or leased employee of the supervising physician, physician group practice, or of the legal entity that employs the physician, or the non-physician must be an independent contractor engaged by the physician through a written agreement; and

(ii) If the non-physician is a leased employee or independent contractor, the physician or legal entity exercises control over the actions taken by the non-physician personnel with regard to the rendering of medical services to the same extent as the physician would exercise if the leased employee or contractor was an employee of the physician or legal entity.

(b) The service must represent an expense to the physician or legal entity.

(2) The department will reimburse an eligible provider of physician services for the following services by non-physicians provided under the general supervision of the physician:

(a) Pregnancy related services as detailed in rule 5101:3-4-10 of the Administrative Code;

(b) Physician services provided by a rural health facility (RHF), federally qualified health center (FQHC) or outpatient health facility (OHF);

(c) Minimal office visits as defined in the "Physicians' Current Procedural Terminology" (CPT). "CPT" as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code;

(d) Pregnancy prevention/contraceptive management visits as defined in rule 5101:3-21-02 of the Administrative Code;

(e) Allergy injections administered by a properly instructed person in accordance with the physician's prescribed plan of treatment;

(f) Services for the diagnosis and treatment of mental and emotional disorders provided by clinical social workers, and professional clinical counselors in accordance with rule 5101:3-4-29 of the Administrative Code. Services provided by licensed social workers and professional counselors must meet the supervision and documentation provisions specified in rule 5101:3-4-29 of the Administrative Code; and

(g) Physician services provided by public health department clinics, rehabilitation clinics, or family planning clinics.

(E) Physician assistants must provide services in accordance with supervision requirements of rule 5101:3-4-03 and Chapter 4730-1 of the Administrative Code.

(F) Except as provided in paragraph (G) of this rule, the following provisions apply:

(1) Services rendered by non-physicians falling under paragraph (D)(2) of this rule must be provided under general supervision;

(2) Other services not falling under paragraph (D)(2) of this rule provided by non-physicians must be provided under direct supervision as described in paragraph (B) of this rule; and

(3) When services are provided by non-physicians, patients' records must be reviewed and countersigned by the supervising physician.

(G) Services provided by non-physicians who have their own provider category/type (e.g. clinical psychologists, advanced practice nurses, occupational therapists, and physical therapists) and are employed by or under contract with a physician's office are not subject to the physician supervision provisions described in this rule. However, a physician's office may not act simply as a billing agent for a non-physician such as a clinical psychologist. The conditions described in paragraph (D)(1) of this rule must be met in order for the services of a non-physician such as clinical psychologist to be covered as a physician service. The non-physicians listed in this paragraph are restricted to the coverage provisions and limitations for their respective provider type.

(H) Eligible providers of physician services may not be reimbursed for physician services provided in a long-term care facility (LTCF), inpatient hospital, outpatient hospital, or emergency room by non-physicians employed by the hospital or LTCF, even though the physician ordered the services.

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
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, 2/17/91, 4/1/92 (Emer), 7/1/92, 5/2/94 (Emer), 7/1/94, 1/1/01, 1/2/04 (Emer), 4/1/04, 2/16/09

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

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 Site differential payments and place of service.

(A) Site differentials.

(1) "Site differential" is a difference in medicaid payment based on the place (site) of service.

(2) If payment for a service is subject to a site differential, then the payment amount is the lesser of the provider's submitted charge or the appropriate fee specified in appendix DD to rule 5160-1-60 of the Administrative Code:

(a) The maximum facility fee applies when the service is rendered at one of the following sites:

(i) A hospital (inpatient hospital, outpatient hospital, emergency department, or inpatient psychiatric facility);

(ii) A skilled nursing facility;

(iii) An ambulatory surgery center (ASC); or

(iv) A community mental health center (CMHC).

(b) The maximum non-facility fee applies when the service is rendered at any other site.

(B) Place of service codes. The centers for medicare and medicaid services (CMS) maintains place of service codes used throughout the health care industry. The following place of service codes affect payment and must be entered on the claim:

(1) The place of service code assigned to "office" must be entered when the service is provided in a physician or professional medical group office that is not a part of an outpatient hospital facility. A physician or group practice office is considered a part of an outpatient hospital facility if the hospital submits claims in an institutional format for hospital services provided in conjunction with the physician's services.

(2) The place of service code assigned to "home" must be entered when the service is rendered in the patient's place of residence except when the patient's place of residence is a long-term care facility.

(3) The place of service code assigned to "hospital" must be entered when the service is provided to an inpatient hospital patient as defined in Chapter 5160-2 of the Administrative Code.

(4) The place of service code assigned to "outpatient hospital" must be entered when the service is provided by a physician or a clinic provider and the hospital submits claims in an institutional format for hospital services provided in conjunction with the physician's services.

(5) The place of service code assigned to "emergency room" must be entered when the service is provided in a hospital emergency room department whether the physician is an emergency room staff physician or not.

(6) One of the place of service codes assigned to "clinics" must be entered in accordance with the type of clinic when the service is rendered in a facility that meets the department's definition of a clinic, the facility possesses a provider number designated with the provider type "clinic" and the clinic is not a part of an outpatient hospital facility. A clinic is considered a part of an outpatient hospital facility if the hospital bills the department using an institutional claim format for hospital services provided in conjunction with clinic services.

(7) The place of service code assigned to "ambulatory surgery centers" must be entered when the service is provided in an ambulatory surgery center that possesses a provider number designated with the provider type ambulatory surgery center.

(8) One of the place of service codes assigned to long-term care facilities (nursing facilities, custodial care facilities, or intermediate care facilities for individuals with intellectual disabilities) must be entered when the service is provided in a long-term care facility.

(9) The appropriate place of service code must be entered when the service is provided in a setting not listed in paragraphs (B)(1) to (B)(8) of this rule and a specific code has been assigned for that location.

(10) The place of service code assigned to "other, unlisted facility" must be entered if a specific place of service code has not been assigned for that location.

(C) When the physician payment rate is dependent on the place of service reported, errors in reporting the place of service may result in an overpayment to the provider.

(1) If a postpayment review of a physician's records reveals that the physician reported the wrong place of service, the provider will be informed of this error and requested to correctly report the place of service on all claims submitted to the department in the future; and

(2) If the error resulted in an overpayment, the department will recoup the overpayment.

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Effective: 12/31/2013
R.C. 119.032 review dates: 10/15/2013 and 12/31/2018
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

5160-4-03 Physician assistants.

(A) Definitions.

(1) "Supervision," for the purposes of this rule, is defined in accordance with Chapter 4730-1 of the Administrative Code.

(2) "Physician assistant," in accordance with Chapter 4730. of the Revised Code, means a skilled person qualified by academic and clinical training to provide services to patients as a physician assistant under the supervision, control, and direction of one or more physicians who are responsible for the physician assistant's performance.

(3) "Supervising physician," for the purpose of this rule, means the physician(s) responsible for the physician assistant's performance, and with whom the physician assistant has a supervision agreement approved by the state medical board of Ohio, in accordance with Chapter 4730-1 of the Administrative Code.

(B) Coverage and limitations.

(1) Services/procedures provided by a physician assistant are covered by medicaid only if:

(a) The services are provided in accordance with Chapter 4730-1 of the Administrative Code;

(b) The services are:

(i) Specified in section 4730.09 of the Revised Code with the exception of the services listed in paragraph (C)(5) of this rule; or

(ii) The services are approved by the state medical board as special services for that physician assistant if the services provided by the physician assistant are beyond the scope of services authorized under division (A) of section 4730.09 of the Revised Code;

(c) The services are within the scope of practice of the physician assistant's supervising physician;

(d) The services are covered by the department in accordance with rule 5101:3-1-60 of the Administrative Code and not specifically excluded from coverage in accordance with paragraph (C) of this rule;

(e) The physician assistant is employed by or under contract with a physician, physician group practice, or clinic; and

(f) The physician assistant provides services in compliance with all applicable state laws (each physician assistant and his/her supervising physician(s) is responsible for compliance with applicable state laws).

(2) The department may reimburse a physician assistant, physician, physician group practice, or clinic for physician assistant evaluation and management services commensurate with his/her training, experience, the scope of practice of the physician assistant's supervising physician, and the physician supervisory plan.

(C) Provisions applicable to medicaid payment for physician assistant services:

(1) Medicaid payment may be made to the physician assistant directly, or to the physician, physician group practice, or clinic employing or contracting with the physician assistant who is providing services in accordance with this rule.

(2) Physician assistant services are subject to the site differential payments in all places of service specified in rule 5101:3-4-02.2 of the Administrative Code.

(3) A physician assistant, physician, physician group practice, or fee-for-service clinic must bill for services provided by a physician assistant using the appropriate procedure code with the UD modifier except as provided in paragraph (C)(4) of this rule.

(4) A physician assistant, physician, physician group practice, or fee-for-service clinic must bill for services provided by a physician assistant using the appropriate procedure code without the UD modifier if:

(a) A physician also provided distinct and identifiable services during a visit or encounter; or

(b) The services are the type usually provided by medical personnel below the physician assistant and/or advanced practice nurse level of education (e.g., collection of specimens, immunizations).

(5) The department will reimburse physician assistants, physicians, physician group practices, and fee-for-service clinic for services provided by a physician assistant:

(a) The lesser of the provider's billed charge or eighty-five per cent of the medicaid maximum for all services billed in accordance with paragraph (C)(3) of this rule; and

(b) The lesser of the provider's billed charge or one hundred per cent of the medicaid maximum for all services billed in accordance with paragraph (C)(4) of this rule.

(6) A physician assistant, physician, physician group practice, or clinic will not be reimbursed for the following when provided by a physician assistant:

(a) Assistant-at-surgery services;

(b) Visits and/or procedures provided on the same date of service by both a physician assistant and his/her supervising physician, employing physician, employing physician group practice, or employing clinic and billed as separate procedure codes;

(c) Consultations and critical/intensive care services (although physician assistants may provide services that are valuable components of a consultation, ultimately a consultation is the responsibility of a physician); and

(d) Services prohibited in accordance with rule 4730-1-03 of the Administrative Code.

(7) A physician assistant, physician, physician group practice, or clinic may be directly reimbursed for services provided in a nursing facility or intermediate care facility for the mentally retarded by a physician assistant, as described in rule 5101:3-3-19 of the Administrative Code.

(8) Reimbursement for services provided by a hospital-employed physician assistant is available only to hospitals.

Effective: 07/01/2012
R.C. 119.032 review dates: 04/16/2012 and 07/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02, 5111.053
Rule Amplifies: 5111.01, 5111.02, 5111.021, 5111.053, Section 309.37.53 of Am. Sub. H.B. 153
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

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

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 Physician visits.

(A) Definitions pertaining to physician visits.

(1) A "physician visit" or an "evaluation and management (E & M) service" is a face-to-face encounter by a physician with a patient for the purpose of medically evaluating or managing the patient except for code 99211, which does not require the presence of a physician.

(2) "Outpatient visits" are visits provided to a patient in a physician's office, a physician's group practice office, a patient's home (excluding long-term care facilities), hospital emergency room, outpatient hospital, or clinic.

(3) "Inpatient visits" are visits provided to a hospital inpatient as defined in rule 5101:3-2-02 of the Administrative Code or visits provided to a patient in a long-term care facility (LTCF).

(4) "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. The following terms are defined in CPT:

(a) New and established patient;

(b) Concurrent care;

(c) Counseling;

(d) Levels of E & M services;

(e) Presenting problem; and

(f) Intra service, face-to-face and unit/floor time.

(B) Providers must select and bill the appropriate visit code. Visits in conjunction with diagnostic or therapeutic codes are billable in accordance with the provisions set forth in rule Chapter 5101:3-4 of the Administrative Code.

(C) Office or other outpatient services.

(1) For the reimbursement of physician services provided to a patient in a physician's office, a professional medical group office, a fee-for-service clinic, or an outpatient hospital, the provider must bill the appropriate code listed in the CPT as office or other outpatient services.

(2) For reimbursement of visits provided to a patient in a rural health clinic, an outpatient health facility or a federally qualified health center, the provider must itemize the appropriate covered code listed under office or other outpatient services in conjunction with the appropriate encounter code for the service and provider type.

(3) After hours care.

(a) The department will compensate providers of physician services for visits provided after regularly scheduled office hours when the services are provided in an office or clinic setting.

(b) Reimbursement for after hours care is in addition to the basic services provided to the patient. For reimbursement, providers should bill the appropriate covered code listed in appendix DD to rule 5101:3-1-60 of the Administrative Code in addition to the surgical and/or visit codes.

(D) Hospital inpatient services.

(1) For the reimbursement of visits provided to hospital inpatients, the provider must bill the appropriate code listed in the CPT under hospital inpatient services in accordance with the instructions and definitions in the CPT.

(2) Hospital care to newborns should be billed in accordance with paragraph (N) of this rule.

(E) Consultations.

(1) A consultation is a type of service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The person requesting the consultation must be a health care professional who is eligible to bill the department for physician services. When a teacher, social worker, or other non-physician (excluding a physician assistant or an advanced practice nurse) requests a physician to evaluate a patient, these services are not reimbursable as a consultation. The physician consultant may also initiate diagnostic and/or therapeutic services.

(2) The request for a consultation from the attending physician or other appropriate source as defined in paragraph (E)(1) of this rule and the need for consultation must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated to the requesting physician or other appropriate source.

(3) A consultation initiated by a patient and/or family, and not requested by a physician, may not be billed using the initial or consultation codes but may be billed using the codes for regular office visits, as appropriate.

(4) If a consultant subsequently assumes responsibility for management of a portion or all of the patient's condition(s), the appropriate evaluation and management services code for the site of service should be reported.

(5) Consultations are subject to the coverage and limitations specified in paragraph (P) of this rule.

(6) Office or other outpatient consultations.

(a) For the reimbursement of consultations provided to patients in an outpatient setting, the provider must bill one of the codes listed in the CPT under office or other outpatient consultation.

(b) When an outpatient consultation code is billed, the provider must submit the required referring physician provider information.

(c) Follow-up visits initiated by and to the consulting physician must be billed using the regular visit codes.

(d) If an additional request for an opinion or advice regarding the same or new problem is received from the attending physician and documented in the medical record, the office and other outpatient consultation codes may be billed.

(7) Inpatient consultations.

(a) Physician consultations provided to a hospital inpatient or to an individual residing in a long term care facility (LTCF) must be billed using the codes listed in the CPT under initial inpatient consultations. Only one initial consultation code should be billed by a consultant per admission.

(b) Subsequent consultative visits requested by the patient's attending physician or subsequent visits required to complete the initial consultation to hospital inpatients or to residents in a LTCF must be billed using the code listed in the CPT for subsequent hospital care or subsequent nursing facility care including services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem.

(c) When an initial inpatient consultation code is billed, the provider must submit the required referring physician provider information.

(F) Emergency department services.

(1) An "emergency department" (sometimes referred to as a "hospital emergency room" or "ER") is defined as an organized, twenty-four-hour, hospital-based facility for the provision of unscheduled episodic services to patients who seek or are in need of immediate medical attention.

(2) Whether or not the provider normally practices in the emergency department setting, evaluation and management services provided in an emergency department must be billed using:

(a) One of the codes listed in the CPT under emergency department services;

(b) The codes for critical care in accordance with paragraph (G) of this rule; and/or

(c) The appropriate surgical procedure codes in accordance with rule 5101:3-4-22 of the Administrative Code.

(3) When ER services are billed using the emergency department E & M codes:

(a) No distinction is made between new and established patients in the emergency department.

(b) ER visits are subject to the coverage and limitations specified in paragraph (P) of this rule.

(4) Surgical codes may be billed in lieu of an E & M service (e.g., code 12006).

(G) Critical care services

(1) Critical care includes the care of critically ill patients as defined in the CPT.

(2) Management of a critically ill patient may be billed using the codes listed in the CPT under critical care services.

(3) Certain services are included in the critical care codes and are not separately reimbursable when the critical care codes are billed. These services are specified in the critical care services section of the CPT.

(4) Critical care begins at the time the physician arrives to begin evaluation and treatment and ends when the physician's presence is no longer required as defined in the CPT.

(a) The critical care codes may be billed to report the total duration of time, to a maximum of two hours, spent by a physician providing constant attention to a critically ill patient even if the time spent by the physician is not continuous on that day.

(b) Code 99291 must be billed to report the first thirty to seventy-four minutes of critical care provided on a given day and code 99292 must be billed to report each additional thirty minutes as defined by the CPT.

(c) If the total duration of time spent with the patient is less than thirty minutes, the provider must bill the appropriate hospital, emergency department, or other visit code.

(d) Inpatient critical care provided to infants twenty-nine days up through twenty-four months of age must be reported with the inpatient pediatric critical care codes 99471 and 99472. These codes must be billed only once per day per physician per patient. Inpatient critical care services provided to neonates twenty-eight days or less should be billed with the inpatient neonatal critical care codes 99468 and 99469 as long as the neonate qualifies for critical services during the hospital stay. Inpatient care for a critically ill or critically injured child older than two years when admitted to an intensive care unit must be billed with hourly critical care codes 99291 and 99292.

(e) Inpatient critical care provided to neonates who are defined as infants twenty-eight days of age or less at the time of admission to a critical care unit, are reported with the neonate critical care codes listed in the CPT book.

(i) Once the neonate is no longer considered to be critically ill, the continuing intensive (non-critical) low birth weight service codes specified in CPT must be used to bill for services subsequent to the day of admission provided by a physician directing the intensive care of the low birth weight or very low birth weight infant who no longer meets the definition of critically ill for those with present body weight of less than five thousand grams, the appropriate E & M code must be billed. When the present body weight of the infant exceeds five thousand grams, bill the appropriate code under subsequent hospital care.

All codes delineated under continuing intensive care services represent subsequent days of care and are reimbursable only once per calendar day per patient. These are considered global codes with the same services bundled as outlined in CPT under "inpatient neonatal and pediatric critical care services."

(ii) Inpatient neonatal and pediatric critical care codes are global twenty-four hour codes and must be billed on a per day basis. Services for a patient who is not critically ill, but happens to be in a critical care unit, must be reported using other appropriate evaluation and management codes.

(iii) Certain procedures are included in the global pediatric and neonatal codes and must not be billed separately. These procedures are specified in the neonatal and pediatric critical care section of the CPT.

(iv) The initial neonatal inpatient critical care code 99468 may be billed as appropriate in addition to 99464 or 99465 when the physician is present for the delivery (99464) and newborn resuscitation (99465) is required. Other procedures performed as part of the resuscitation such as endotracheal intubation (31500) should be billed separately if they are performed as a necessary component of the resuscitation and not as a convenience before admission to the neonatal intensive care unit.

(v) Critical care services provided in the outpatient setting, e.g. emergency department or office for neonates and pediatric patients up through twenty-four months of age, should be billed with the critical care codes 99291 to 99292.

(vi) If the same physician provides critical care services for a neonatal or pediatric patient in both the outpatient and inpatient settings on the same day, bill only the appropriate neonatal or pediatric critical care code (99471 to 99469) for all critical care services provided that day.

(H) Other evaluation and management service- initial intensive hospital care for the management of a neonate, twenty-eight days of age or less.

(1) Initial hospital care for the evaluation and management of neonates twenty-eight days or less requiring intensive observation, frequent interventions, and other intensive care services are reported under the other evaluation and management services code listed in the CPT book.

(2) Initial hospital care for the evaluation and management of neonates twenty-eight days or less requiring intensive observation, frequent interventions, and other intensive care services is a global twenty-four hour code and must be billed once per admission and on the first day of care.

(3) For the initiation of inpatient hospital care of a normal newborn, or a critically ill neonate, or for initial inpatient hospital care of a neonate not requiring intensive observation, frequent interventions, and other intensive care services, bill the codes specified in the CPT.

(4) CPT code 99477 will not be reimbursed when billed on the same date of service with CPT codes 99468 or 99221 through 99223.

(5) Subsequent inpatient hospital intensive care services provided to neonates are reported following CPT guidelines under the subsequent inpatient neonatal critical care code.

(I) Transitional care management services.

(1) These services are for individuals whose medical and or psychosocial problems require moderate or high complexity medical decision making during a transition in care from an acute hospital or other acute care facility setting to the individual's community setting.

(2) Transitional care management is comprised of one face-to-face visit within the specified time frames, in combination with non face-to-face services performed by a physician or other qualified healthcare professional.

(3) Non face-to-face services include but are not limited to communication with the individual or family member regarding aspects of care, assessment and support of treatment regimen and/ or medication management, identifying available community resources, facilitating access to care or services for the individual, and educating the individual, family member and/ or caregiver.

(4) The complexity of the medical decision making and the date of the first face-to-face visit are used to report the appropriate transitional care management code.

(J) Nursing facility services.

(1) A physician may not be directly reimbursed for a LTCF visit if the service provided is the periodic review of a resident's medical record, plan of care, and/or habilitation plan and a face-to-face encounter with the patient is not provided.

(2) A physician may be reimbursed for one LTCF visit, per patient, per date of service, as detailed in rule 5101:3-3-19 of the Administrative Code and only if the physician personally performed a physical examination on a LTCF resident and documented the visit in the resident's medical record. The guidelines listed in the CPT for LTCF codes must be followed.

(3) A physician may also be reimbursed for a LTCF visit provided by a physician assistant (PA) or nurse practitioner under the physician's employment in accordance with rule 5101:3-3-19 of the Administrative Code.

(K) Domiciliary, rest home (e.g., boarding home) or custodial care services.

Visits provided to patients in a facility that does not meet the definition of a LTCF, such as a domiciliary, rest home, or custodial care service facility, (e.g., boarding home or assisted living facility), that provides room, board and other personal assistance services, must bill using the visit codes listed in the CPT under domiciliary, rest home, or custodial care services.

(L) Domiciliary, rest home, or home care plan oversight services.

Codes listed in this section of the CPT are not separately reimbursable, but are bundled into other services performed.

(M) Home services.

For visits provided to a patient confined to his or her private residence ("homebound patient"), the provider must bill the appropriate code listed in the CPT under home services.

(N) Newborn care.

(1) Predelivery visit to a pediatrician or other primary care physician.

(a) To encourage families to obtain early and continuous well-child and primary sick care for their newborn, the department will cover a predelivery visit to a pediatrician or other primary care provider of physician services. The purpose of this service is to give the mother (or family) the opportunity to select, and establish a patient relationship with, a physician for the care of her (their) newborn.

(b) For reimbursement of this service, the provider must bill the appropriate evaluation and management code.

(2) The newborn care codes should be used for the following:

(a) The initial history and examination of a normal newborn delivered in a hospital or birthing room setting;

(b) Subsequent hospital care provided to a normal newborn on a per day basis;

(c) Initial history and examination of a normal newborn delivered in a setting other than a hospital or birthing room setting; and

(d) Initial history and examination of a high-risk newborn in accordance with paragraph (N)(3) of this rule.

(3) Pediatrician delivery services for high risk newborns and newborn resuscitation services.

A "high-risk newborn" shall be defined as an infant who is delivered by Cesarean or determined, prior to (or after) the immediate delivery, to be at-risk of prematurity or a poor prognosis.

(a) Services of a pediatrician, when requested by the delivering physician, in attendance at a delivery and for the initial stabilization of a high risk newborn or a Cesarean section may be billed using code 99464. This code cannot be used when the billing physician does any of the following while in attendance at the delivery:

(i) Provide care or services to other patients;

(ii) Perform a procedure subject to a surgical package; or

(iii) Proctor another physician.

(b) The newborn resuscitation code may be billed only if resuscitation services are actually provided to the newborn. This service involves the provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.

(c) The newborn resuscitation code and the physician attendance codes may be billed with the codes for newborn care, neonatal intensive care and hospitals visits.

(4) Subsequent care of a sick newborn in an inpatient hospital setting must be billed using the subsequent hospital visit codes or the newborn critical care codes in the CPT.

(5) Routine well baby care provided in an outpatient setting should be billed in accordance with Chapter 5101:3-14 of the Administrative Code.

(6) Subsequent care of a sick newborn in an outpatient setting should be billed using the codes for outpatient E & M services.

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

(1) The department will recognize initial observation care for patients who are treated in a hospital and the patient's condition does not require an inpatient hospital admission but does require a period of medical observation for less then twenty-two hours . To bill for initial observation care, the provider must bill the appropriate code in the CPT under the initial observation care section.

(2) It is only appropriate to bill hospital observation E & M services provided to patients designated as "observation status" in a hospital. Billing hospital observation services for emergency department services is inappropriate.

(3) For a patient admitted to the hospital on a date subsequent to the date of observation status, the hospital admission should be reported with the appropriate initial hospital care code.

(4) If patient care during observation services results in a hospital admission and the physician who provided the initial observation care continues to be the patient's attending physician after the admission, the physician must bill the hospital inpatient E & M codes in lieu of the initial observation codes.

(5) If patient care during observation services results in a hospital admission on the same date that observation care was initiated and the physician who provided the observation care does not continue to be the patient's attending physician after the admission, (care is transferred to another physician), the physician who provided the observation care may bill for the initial observation services and the new attending physician may bill a hospital inpatient E&M code.

For a patient admitted and discharged from observation or inpatient status on the same date, the services should be reported with the appropriate code listed under the "observation or inpatient care services (including admission and discharge services)" section of the CPT.

(6) Do not report an observation discharge in conjunction with a hospital admission.

(7) Observation codes may not be utilized for post-operative recovery if the service is considered a global surgical procedure code.

(P) Limitations on physician visits.

(1) Outpatient visits.

(a) Reimbursement will be made for all physician visits provided to a recipient in an outpatient or an LTCF setting during a calendar year up to a total of twenty-four visits.

(b) Physician visits in excess of twenty-four will be paid as the services are billed to the department but will be subject to post-payment review by the department.

(c) The total number of physician visits accrued by a recipient during a calendar year will be calculated by the department and shall be referred to as the year-to-date visit total.

(d) The following codes will be counted as a physician visit and added to the recipient's year-to-date visit total, unless the codes are billed on an institutional claim form or institutional electronic transaction or the codes are billed with one of the diagnoses listed in paragraph (P)(1)(d)(vi) of this rule:

(i) Codes 99050 to 99051;

(ii) Codes 99304 to 99310, 99315 to 99318, 99324 to 99328, and 99334 to 99337;

(iii) Codes 99241 to 99255 when the service is provided in a setting other than inpatient hospital;

(iv) Codes 99201 to 99215;

(v) Codes 99281 to 99285; and

(vi) Codes 99341 to 99350.

The year-to-date visit total will be an accumulative total of visits provided by all providers of physician services, including but not limited to all physicians, clinics, and podiatrists.

(e) The following physician visits shall be exempted from counting towards the recipient's year-to-date visit total:

(i) All antepartum and postpartum visits as detailed in rule 5101:3-4-08 of the Administrative Code and all pregnancy related services as detailed in rule 5101:3-4-10 of the Administrative Code;

(ii) All well-child or EPSDT (healthchek) visits as detailed in rule 5101:3-14-04 of the Administrative Code;

(iii) All inpatient hospital and critical care visits as defined in this rule;

(iv) Allergen immunotherapy services not billed in conjunction with a code listed in paragraph (P)(1)(d) of this rule;

(v) All other visits or services billed under a code not listed in paragraph (P)(1)(d) of this rule;

(vi) All visits provided for the following diagnoses:

(a) End-stage renal disease;

(b) Chemotherapy or radiation therapy for malignancy;

(c) End-stage lung disease;

(d) Unstable diabetes or diabetes with complications;

(e) Uncontrolled hypertension or hypertension with complications;

(f) Neoplasms and leukemia;

(g) Organ transplants;

(h) Hereditary anemias;

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

(j) Acquired hemolytic anemias;

(k) Aplastic anemias;

(l) Deficiency of humoral immunity;

(m) Deficiency of cell-mediated immunity;

(n) Combined immunity deficiency;

(o) Cystic fibrosis;

(p) Malabsorption;

(q) Failure to thrive;

(r) Infant prematurity;

(s) Respiratory distress syndrome and other respiratory conditions of the fetus and newborn; and

(t) Terminal stage of any life-threatening illness.

(vii) For a visit not to count towards the year-to-date visit total, the provider must bill either a code indicating an exempted service was provided or the visit code with the primary or secondary diagnosis code indicating the patient has one of the exempted conditions.

(f) When the department has paid for more than twenty-four unexempted physician visits for a recipient during a calendar year, information from paid claims history will be reviewed by the department to determine whether the recipient should be referred to a coordinated services program (which is defined in Chapter 5101:3-20 of the Administrative Code).

(i) In addition, the department or its contractual designees may:

(a) Review the medical records of any recipient exceeding twenty-four visits during a calendar year to determine whether the services were medically necessary and appropriate for the recipient's illness, symptoms or injury; and/or

(b) Conduct an in-depth review of any provider and the provider's medical records if the provider shows an unusual pattern of providing greater than twenty-four visits to medicaid recipients.

(ii) If the department determines that the physician visits were not medically necessary in accordance with rule 5101:3-1-01 of the Administrative Code, the payment for the visits may be recovered from the provider by the department.

(2) Inpatient hospital visits.

(a) Inpatient hospital visits, excluding critical care visits, shall be limited to one visit per day per patient per provider.

(b) Critical care visits must be billed in accordance with paragraph (G) of this rule.

(c) Critical care codes may not be billed in conjunction with a hospital or emergency room visit.

(3) Visits related to surgical procedures.

(a) A preoperative examination related to a particular surgical procedure is not separately reimbursable either when it is performed on the day of surgery or after the decision to have surgery has been made.

(b) For each surgical procedure, a postoperative period, expressed in days, is shown in appendix DD to rule 5101:3-1-60 of the Administrative Code. The day of surgery is included in the postoperative period. For reimbursement purposes, the length of a postoperative period may be adjusted if two surgical procedures are performed within a certain number of days of one another.

(i) If two surgical procedures are performed on the same day, then the longer postoperative period applies to both procedures.

(ii) If a second surgical procedure is performed within the postoperative period of another surgical procedure, then the number of days remaining in the postoperative period of each procedure is set equal to the greater of two figures:

(a) The number of days remaining in the unadjusted postoperative period of the first surgical procedure; or(b)The number of days remaining in the unadjusted postoperative period of the second surgical procedure.

(c) A blood draw or transfusion procedure performed on the day of surgery is separately reimbursable only if the physician customarily charges all patients for the procedure.

(d) Reimbursement for all routine postoperative care is included in the payment for surgical procedures. A routine postoperative visit is not separately reimbursable even if it is made after the postoperative period has ended.

(e) A nonroutine postoperative visit made to a physician during the postoperative period is separately reimbursable if one of the following conditions is met:

(i) The physician also performed the surgical procedure, and the visit was made for the diagnosis or treatment of a symptom, illness, or condition unrelated to the surgical procedure.

(ii) The physician did not perform the surgical procedure.

Effective: 09/01/2013
R.C. 119.032 review dates: 06/17/2013 and 09/01/2018
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
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, 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, 12/31/2008 (Emer), 03/31/2009, 08/02/2011, 12/31/2012 (Emer), 03/28/2013

5160-4-06.1 Physician attendance during patient transport.

(A) The following paragraphs apply to patient transports for both pediatric patients twenty-four months of age or less and patients older than twenty-four months of age:

(1) Face-to-face time begins when the physician assumes responsibility of the patient at the referring facility/hospital and ends when the receiving facility/hospital accepts responsibility for the patient's care. Only the time the physician spends in direct face-to-face contact with the patient during the transport may be billed.

(2) Services provided by other members of the transport team must not be billed by the physician, but must be billed by the transportation company (e.g., ambulance provider).

(3) Routine monitoring evaluations (e.g., heart or respiratory rate, blood pressure, pulse oximetry, and the initiation of mechanical ventilation) are included in the face-to-face time reported in the patient transport codes and will not be paid separately.

(4) The direction of emergency care to transporting staff by a physician located in a hospital/facility by two-way communication is not considered direct face-to-face care and must not be reported using the patient transport codes.

(5) The patient transport services are covered by the department only if the service is personally provided by a physician.

(6) The codes for the initial care of the critically ill or critically injured patient may be billed only once on a given date.

(B) The following paragraphs apply to patient transports of pediatric patients:

(1) The procedure codes 99466 and 99467 for pediatric patient transport found in rule 5101:3-1-60 of the Administrative Code are used to report the physical attendance and direct face-to-face time spent by a physician during the inter- facility transport of a critically injured or critically ill pediatric patient twenty-four months of age or less.

(2) These procedure codes are time-based. Pediatric patient transport services involving less than thirty minutes of face-to-face physician care may not be reported using the patient transport codes.

(3) Certain procedures are included in the global critically ill or critically injured pediatric patient transport codes and may not be billed separately. These procedures are specified in the pediatric critical care patient transport section of the current procedural terminology (CPT).

(C) The following paragraphs apply to patient transports for individuals older than twenty-four months of age:

(1) Critical care codes 99291 and 99292 should be billed when a physician is in attendance during the transport of a critically ill or critically injured patient over twenty-four months of age to or from a facility/hospital.

(2) When billing the critical care codes specified in paragraph (C)(1) of this rule for a patient transport, the provider must use modifier "UB" to indicate that the code is being billed for a patient transport for a critically ill or injured patient over twenty-four months of age. When billing 99292 for a critically ill patient who has had a physician in attendance during the patient transport and then received critical care in the hospital, bill 99292 UB for the time the physician spent in attendance during the transport. Bill code 99292 unmodified for the time spent providing critical care in the hospital.

(3) The critical care code policies specified in rule 5101:3-4-06 of the Administrative Code apply to patient transports billed with critical care codes, except that there is no maximum time limit for the face-to-face physician time spent during the transport of a critically ill or injured patient over twenty-four months of age.

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, 5111.021
Prior Effective Dates: 12/31/01 (Emer), 3/29/02, 7/1/03, 10/25/08, 12/31/08 (Emer), 3/31/09

5160-4-08 Covered obstetrical services.

(A) Providers of obstetrical services must bill each antepartum visit, separately. The department does not recognize the codes for "global obstetrical care" which bundle these services under a single procedure code. The department does recognize the code for delivery and postpartum services which may be billed using a single procedure code when the services are provided by the same provider.

(B) The following obstetrical services are covered as detailed below:

(1) Prenatal risk assessment;

(2) All antepartum care including pregnancy related services;

(3) Delivery; and

(4) Postpartum care.

(C) Prenatal risk assessment (PRA)

(1) The "Prenatal Risk Assessment (PRA)" form, JFS 03535, is a checklist of medical and social factors which is used as a guideline to determine when a patient is at risk of a preterm birth or poor pregnancy outcome.

(2) The PRA form must be completed on each obstetrical patient during the initial antepartum visit in order to bill for the prenatal at-risk assessment code. A copy of the PRA form should be placed in the patient's record to serve as documentation that the service was provided.

(3) Providers must submit a copy of the PRA form to the patient's residential county department of job and family services since the county staff can assist patients obtaining needed services.

(4) When significant risk factors that were not noted on the original PRA form are identified during the course of the pregnancy, providers are encouraged to complete another risk assessment form and to send a copy to the county department of job and family services.

(5) Providers may receive reimbursement for completing the PRA form by billing the code for prenatal risk assessment specified in rule 5101:3-4-10 of the Administrative Code.

(D) Antepartum care

(1) Antepartum visits

(a) The antepartum visit is inclusive of:

(i) Instruction, education and counseling on a variety of topics related to pregnancy, nutrition, baby-care and family;

(ii) Routine urinalysis screening tests (dipstick) to detect the presence of sugar or protein;

(iii) A physical examination which includes recording of weight, blood pressure, and fetal heart tones or similar routine services;

(iv) Coordination of the patient's medical care including at a minimum a planned hospital delivery, arrangements for medical care and/or consultation (by telephone) in case of an emergency, and referrals to appropriate medical services (i.e., ultrasounds, etc.).

(b) Medical care coordination, education and counseling services provided as part of the antepartum visit should be consistent with those services generally required for all obstetrical patients. When the care coordination and/or counseling and educational services provided to an individual are more extensive than the services routinely provided to obstetrical patients, a provider may be compensated for these services by billing the pregnancy related services detailed in rule 5101:3-4-10 of the Administrative Code.

(c) Antepartum visits must be billed to the department on a per-visit basis using the evaluation and management (office visit) code appropriate for the type of visit documented in the patient's record. When the antepartum visit is billed, specify a diagnosis to signify pregnancy such as V22 for supervision of normal pregnancy, V23 for supervision of a high-risk pregnancy, or V28 for antenatal screening. Bill the code modified by the "TH" modifier to signify "obstetrical services, prenatal or post-partum".

(2) Additional services

(a) In addition to the antepartum visit, reimbursement is available for the following services provided during the antepartum and postpartum periods:

(i) Pregnancy related services which are described in rule 5101:3-4-10 of the Administrative Code.

(ii) All obstetrical-related radiology and laboratory procedures (with the exception of urinalysis screening tests) actually performed in the physician's office;

(iii) All obstetrical diagnostic procedures identified in standard code sets; and

(iv) All covered medical services provided in addition to the antepartum visit.

(b) The services listed in paragraph (D)(2)(a) of this rule may be provided independently on any date of service, or they may occur sequentially on the same date as the antepartum visit or any other covered service.

(E) Delivery and postpartum care.

(1) "Delivery services" include admission to the hospital, the admission history and physical examination, management of uncomplicated labor, vaginal delivery (with or without forceps and/or episiotomy), or Cesarean section delivery.

(2) "Postpartum care" includes hospital and office visits for routine, uncomplicated care following a vaginal or Cesarean section delivery.

(3) Under paragraph (E) of this rule, "same provider" means the rendering provider or any member of the same group practice.

(4) The following codes should be billed:

(a) For delivery and postpartum services provided to patients for which a vaginal or Cesarean delivery after a previous Cesarean delivery (VBAC) was not attempted.

59409 For a vaginal delivery when outpatient postpartum care is provided by another provider or provider group.

59410 For a vaginal delivery when outpatient postpartum care is provided by the same provider or provider group.

59514 For a Cesarean section when outpatient postpartum care is provided by another provider or provider group.

59515 For a Cesarean section when outpatient postpartum care is provided by the same provider or provider group.

(b) For delivery and postpartum services provided on or after January 1, 1996 to patients for which a VBAC was attempted.

59612 For a vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) when outpatient postpartum care is provided by another provider or provider group.

59614 For a vaginal delivery only, after previous Cesarean delivery (with or without episiotomy and/or forceps) when outpatient postpartum care is provided by the same provider or provider group.

59620 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery when outpatient postpartum care is provided by another provider or provider group.

59622 Cesarean delivery only, following attempted vaginal delivery after previous Cesarean delivery when outpatient postpartum care is provided by the same provider or provider group.

(c) Postpartum care when performed as a separate procedure.

59430 For postpartum care only.

(5) For the reimbursement of codes 59410, 59430, 59515, 59614 or 59622, the provider must, at a minimum, render an evaluation and management service four to six weeks post-delivery.

(6) Under the medicaid program, the provision of postpartum care rendered prior to discharge from the inpatient hospital, outpatient hospital or birthing center (i.e. the delivering institution) is considered incidental to the delivery services and/or postpartum service and should not be a factor when selecting the delivery only codes or the delivery codes bundled with the postpartum care services.

(a) For the reimbursement of the delivery only codes the provider or provider group must render, at a minimum, the delivery service;

(b) For reimbursement of the delivery and postpartum care codes, the provider or provider group practice must render, at a minimum, bot the delivery and at least one evaluation and management service four to six weeks post-delivery;

(c) For the reimbursement of the postpartum care only code, the provider or provider group practice must render, at a minimum, at least one evaluation and management service four to six weeks post surgery.

(7) Additional reimbursement will not be recognized for the complexity of the delivery, for multiple births, or for two physicians performing the same vaginal delivery.

(8) Reimbursement is available for inpatient and outpatient evaluation and management services provided for post-delivery complications or services unrelated to the delivery in accordance with paragraph (M)(3) of rule 5101:3-4-06 of the Administrative Code.

(9) Services of an assistant-at-surgery during a Cesarean delivery are covered in accordance with paragraph (G) of rule 5101:3-4-22 of the Administrative Code.

(10) Services of a pediatrician in attendance at a delivery of a high risk newborn or a Cesarean section are covered in accordance with rule 5101:3-4-06 of the Administrative Code.

(11) All pregnancy related services are covered services during the postpartum period with the exception of high-risk patient monitoring and the predelivery visit.

(F) Transportation services for pregnant women to medicaid covered services will be provided by the patient's residential county department of job and family services, if it is requested by the provider, the recipient or other person acting on the recipient's behalf.

Eff 4-7-77; 12-21-77; 12-30-77; 1-8-79; 2-1-80; 4-1-88; 9-1-89; 5-1-90; 2-14-92 (Emer.); 5-14-92; 12-30-93 (Emer.); 3-31-94; 3-30-95; 12-29-95 (Emer.); 3-21-96; 5-9-96; 7-1-03
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.02
R.C. 119.032 review dates: 10/08/2002 and 07/01/2008

5160-4-08.1 Payment for prenatal visits.

(A) Paragraph (D)(1)(c) of rule 5101:3-4-08 of the Administrative Code specifies that providers billing for an antepartum/prenatal visit must bill the code for an evaluation and management office visit to receive reimbursement for a prenatal visit. Providers must choose the office visit code appropriate for the visit documented in the patient's record and modify the code by the "TH" modifier to signify that the visit was for prenatal services.

(B) When the "TH" modifier is billed with an office visit code, the following reimbursement will be made effective for dates of service on and after July 1, 2008:

Office Visit Type Codes Medicaid Maximum

new patient 99201 to and including 99202 $ 49.85

new patient 99203 see rule 5101:3-1-60 of the Administrative Code

new patient 99204 see rule 5101:3-1-60 of the Administrative Code

new patient 99205 see rule 5101:3-1-60 of the Administrative Code

established patient 99211 $ 19.73

established patient 99212 to and including 99213 $ 49.85

established patient 99214 see rule 5101:3-1-60 of the Administrative Code

established patient 99215 see rule 5101:3-1-60 of the Administrative Code

(C) Providers must follow the instructions for selecting the level of evaluation and management service specified in the "CPT" manual. "CPT" as used in this rule is defined in rule 5101:3-1-19.3 of the Administrative Code.

Effective: 07/01/2008
R.C. 119.032 review dates: 09/25/2007 and 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 10/1/03

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

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 Pregnancy related services.

(A) "Pregnancy related services" identified in paragraphs (B) to (F) of this rule are optional preventive health services available to all medicaid-eligible women. These services are intended to promote positive birth outcomes by supplementing regular obstetrical care. Services identified in paragraphs (G) and (H) of this rule are covered services for women who need therapeutic intervention to prevent poor birth outcome.

(1) Pregnancy related services may be delivered by physicians, hospitals, clinics, rural health clinics, outpatient health facilities, federally qualified health centers, and advanced practice nurses who are eligible medicaid providers. When provided, these services must be billed in accordance with the specific billing requirements and procedures for the provider type of the rendering provider as specified in Chapter 5101:3 of the Administrative Code.

(2) These services may also be delivered, but not billed directly, by health care professionals (e.g., dietitians, social workers) who are not eligible medicaid providers, if the services provided are within the professional's scope of practice and the professional is employed by or under contract with an eligible medicaid provider.

(3) Pregnancy related services may be provided in a patient's home or at the provider's practice site.

(4) When billing for pregnancy related services listed in this rule with the exception of the predelivery visit to a pediatrician or other primary care provider, follow the billing instructions listed in this paragraph:

(a) Bill the appropriate code(s) specified in this rule with the modifier "TH" to indicate that obstetrical services, prenatal or post-partum, were provided.

(b) Bill the appropriate diagnosis code to indicate that the diagnosis is for antepartum care- either V22, V23, or V28.

(B) Care coordination

(1) A provider may be reimbursed a monthly care coordination fee (once every four weeks) if the provider furnishes all the following services, as appropriate, to the patient:

(a) Performs a social/psycho social assessment identifying factors which may affect the patient's ability to follow prescribed care and necessary social services.

(b) Develops a written individual care plan which includes a timetable for the delivery of medical services as prescribed by the physician or nurse midwife and any recommended social services.

(c) Assists the physician and patient in the scheduling and coordination of services identified in the care plan;

(d) Reviews the care plan at least once every four weeks and updates the plan to reflect any revisions;

(e) Provides a copy of the care plan to the patient;

(f) Makes necessary referrals for nonmedical services, including but not limited to:

(i) County department of job and family services for needed transportation, casework, or social services (e.g., food, clothing, shelter, etc.);

(ii) Special supplemental food program for women, infants, and children (WIC); and

(iii) Other social service agencies as needed (e.g., child support, children services, mental health, drug and alcohol);

(g) Makes telephone contact or provides a written reminder for the patient prior to all appointments;

(h) Telephones the patient or sends a written notice of any missed appointments and makes arrangements with the patient to reschedule the appointment. Requests assistance from the at-risk pregnancy coordinator at the patient's residential county department of job and family services when the patient is noncompliant in keeping appointments (e.g., misses back-to-back appointments).

(2) For reimbursement, the provider must bill code H1002. This code may be billed on the initial date of service and once every twenty-eight days thereafter.

(C) Group pre-natal at-risk education

(1) Group education classes on a variety of topics relating to pregnancy, birth, childcare, nutrition, family and support systems are covered on a per class basis. (E.g., Lamaze or other childbirth classes would be considered a covered group education service).

(2) Group education may be a single class covering a single topic or multiple topics or it may be a series of classes covering a single topic or multiple topics.

(3) Group education classes must consist of a face-to-face presentation by a medical professional in a group of no more than twelve patients (not including partners/coaches).

(4) For reimbursement, the provider must bill the appropriate code listed in this paragraph to indicate the type of group session attended by the recipient. The unit of service for each session (one or more classes) is limited to one per pregnancy. The following group education sessions for pregnancy session are covered by medicaid effective with services provided on and after the effective date of this rule:

(a) For childbirth preparation/Lamaze classes, non-physician provider, per session, bill S9436.

(b) For childbirth refresher classes, non-physician provider, per session, bill S9437;

(c) For nutrition classes provided to pregnant women by a non-physician provider, per session, bill S9452.

(d) For baby parenting classes provided to pregnant women by a non-physician provider, per session, bill S9444; and

(e) For infant safety classes provided to pregnant women by a non-physician provider, per session, bill S9447.

(D) Individual counseling and education

(1) When the counseling and educational services exceed those normally provided during a prenatal visit, focus primarily on the specific needs of the individual, and involve an individual face-to-face encounter of approximately fifteen minutes or more, the provider may be paid for an individual counseling and education service in addition to the antepartum visit.

(2) For reimbursement, the provider must bill code H1003.

(E) Predelivery visit to a pediatrician or other primary care provider

(1) To encourage families to obtain early and continuous well-child and primary care for their newborn, the department covers pre-delivery visits to a pediatrician or other primary care physicians. The purpose of this service is to give the mother (or family) the opportunity to select, and establish a patient-physician relationship with, a physician for the care of her (their) infant.

(2) For reimbursement, the provider must bill the most appropriate evaluation and management (visit) code.

(F) High-risk patient monitoring/antepartum management

(1) A provider may be reimbursed for high-risk patient monitoringnow known as antepartum management provided on a weekly basis to a patient who has been determined by the provider to be at-risk of a preterm birth.

(2) "High-risk patient monitoring"/antepartum management is a service which includes counseling and educational services associated with identifying and reducing the risks of a preterm labor, telephone or face-to-face contact with the patient a minimum of three times a week to identify signs of preterm labor and accessibility of the provider to the patient in the event the patient begins to show signs of preterm labor.

(3) High-risk patient monitoring/antepartum management must be provided by a health care professional who is qualified to identify the signs of preterm labor and is employed by or under contract with an eligible provider of physician services.

(4) For reimbursement, the provider must bill code H1001 for antepartum management.

(G) Nutrition intervention

(1) Basic nutrition education and counseling services are considered a part of routine antepartum care.

(2) "Nutrition intervention" is a service provided to a pregnant or postpartum woman who has a medical need for a therapeutic diet. Nutrition intervention includes the following:

(a) Specialized nutrition counseling and education as it relates to the medically diagnosed problem or high-risk factor;

(b) Development of an individual diet plan, including a therapeutic diet calculation;

(c) Teaching of therapeutic diet or other nutritional modifications of diet, and the provision of sample meal plans and patterns;

(d) Monitoring the results of the nutrition intervention and making any necessary changes in the dietary plan.

(3) Nutrition intervention may be delivered by a physician or a dietitian who is licensed by the state of Ohio or who has equivalent qualifications if practicing outside the state.

(4) Dietitians delivering nutrition intervention may not bill for the service directly but must be under contract with or employed by an eligible medicaid provider.

(5) For reimbursement, the provider must bill code, S9470 for medical nutrition therapy counseling for pregnant women provided by a dietician employed by or under contract with an eligible medicaid provider. For nutrition therapy provided by a physician, bill the appropriate evaluation and management code with diagnosis code V22, V23, or V28. In both cases, the "TH" modifier must be billed to reflect that the nutrition intervention is for prenatal at-risk educational purposes and the appropriate pregnancy diagnosis code must be billed.

(6) For group nutrition classes which are described in paragraph (C) of this rule, bill the code S9452.

(H) Prenatal risk assessment

(1) Providers may receive reimbursement for a prenatal risk assessment if the provisions described in paragraph (C) of rule 5101:3-4-08 of the Administrative Code are met.

(2) To receive reimbursement for a prenatal risk assessment, providers must bill code H1000.

(I) Reimbursement

(1) Payment for pregnancy related services provided by providers of physician services in an office or fee-for-service clinic setting will be the provider's billed charge or the payment amount listed in appendix DD of rule 5101:3-1-60 of the Administrative Code.

(2) When pregnancy services are provided by the hospital to hospital outpatients, the hospital will be reimbursed the rates listed in appendix F of rule 5101:3-2-21 of the Administrative Code.

Eff 4-1-88; 5-15-89; 2-14-92; 1-1-01; 7-1-03
Rule promulgated under: RC 119.03
Rule authorized by: RC 5111.02
Rule amplifies: RC 5111.01, 5111.02
R.C. 119.032 review dates: 10/08/2002 and 07/01/2008

5160-4-11 Diagnostic and therapeutic procedures.

(A) This rule sets forth the policy for the submission of professional (26) and technical (TC) modifiers and the place of service restrictions for diagnostic and therapeutic procedure codes. Numeric values and lower case alpha characters that may accompany a PCTC indicator are defined in paragraph (B) of this rule. The procedure codes with a PCTC indicator are set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(B) PCTC indicator policy:

(1) Diagnostic and therapeutic codes that consist of technical and professional components defined by the use of the 26/TC modifier are identified by a PCTC indicator of 1.

(a) If the code is unmodified or modified with a TC modifier the code is not covered in a hospital setting.

(b) If the code is modified with a 26 modifier there are no place of service restrictions.

(2) Diagnostic and therapeutic codes that the definitions distinguish as professional only, technical only or global/complete are identified by a PCTC indicator of 2, 3, or 4, respectively.

(a) Professional only procedures may be performed in any setting.

(b) Global/complete procedures or technical only procedures may not be reimbursed in a hospital setting.

(3) Diagnostic and therapeutic codes that are professional only codes are identified by a PCTC indicator of 0 or 9. Any indicator that is accompanied by a lower case alpha character, for example 0c, indicates place of service restrictions in accordance with paragraph (B)(5) of this rule.

(4) Diagnostic and therapeutic codes that are technical only codes or are considered a hospital facility or long term care facility services when performed in an institutional setting are identified by a PCTC indicator 5, 7, or 9. Any indicator that is accompanied by a lower case alpha character, for example 7c, indicates place of service restrictions in accordance with paragraph (B)(5) of this rule.

(5) The alpha values below identify exceptions to the general place of service guidelines. These lower case alpha characters may accompany any PCTC indicator to define additional place of service restriction(s).

(a) Lower case value (a) means only an inpatient hospital place of service is allowed.

(b) Lower case value (b) means the service is not separately reimbursable when performed in an inpatient hospital, outpatient hospital, or emergency room.

(c) Lower case value (c) means the service is not separately reimbursable when performed in an inpatient hospital, outpatient hospital, emergency room, or long-term care facility.

(d) Lower case value (d) means the service is only allowed in an office, clinic, or urgent care place of service.

(e) Lower case value (e) means the service is allowed in the home only.

(f) Lower case value (f) means the service is not separately reimbursable when performed in an inpatient hospital.

(g) Codes with no lower case value do not have place of service restrictions.

(C) Limited practitioners, chiropractors, physical therapists, occupational therapists, and psychologists have additional place of service restrictions in accordance with Chapter 5101:3-4 of the Administrative Code.

Replaces: 5101:3-4-11

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: 4/1/92 (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

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

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.

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.

(A) Routine maintenance dialysis.

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

(2) The following services may be billed in addition to the MCP:

(a) The declotting of shunts; and

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

(3) To receive the MCP, the physician must bill the department on the last day of the month using the appropriate CPT (as defined in rule 5101:3-1-19.3 of the Administrative Code) code (90951 to 90966).

(a) Several physicians may form a team to provide the monthly continuity of services to a single patient or to a group of ESRD patients, or a physician 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 provision arrangements. Under a joint provision, each physician may cover for the other and the MCP may be billed by and reimbursed to the primary physician. The primary physician must make arrangements to compensate the other physicians involved in the dialysis care of the patient(s).

(b) When the dialysis care of a patient is provided by more than one physician during a calendar month and there is not a joint provision arrangement between the physicians, the physicians who provided the split services during the month must bill the department separately using the appropriate CPT code (90967 to 90970) for each day the physician 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 (codes 90951 to 90966);

(ii) More than thirty-one days of dialysis care (codes 90967 to 90970); or

(iii) Payment for the MCP and daily dialysis care (any combination of codes 90951 to 90970).

(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), reimbursement for the professional services associated with the dialysis is still considered routine maintenance dialysis and is only reimbursable on a MCP basis.

(B) Inpatient dialysis services.

(1) Except as provided for in paragraph (A)(4) of this rule, physicians may be paid on a fee-for-service (procedure code) basis for physician professional services provided to hospital inpatients. To be eligible for reimbursement on a fee-for-service basis, the physician must be present with the patient some time during the dialysis, the patient's medical records must document that the physician 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 that is unrelated to the patient's renal condition and the physician has elected to bill the inpatient dialysis services on a fee-for-service basis. If the physician has elected to bill the inpatient dialysis services on a fee-for-service basis and the physician usually is paid the MCP, the physician may not bill for the MCP (CPT codes 90951 to 90966) that month and must bill using the appropriate CPT code (90967 to 90970) only for the days the patient was not a hospital inpatient.

(2) For reimbursement for inpatient dialysis services on a fee-for-service basis, the provider must bill the appropriate dialysis code from the range of 90935 to and including 90947.

(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 codes 90935 to 90947.

Effective: 03/31/2009
R.C. 119.032 review dates: 03/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 9/1/89, 5/25/91, 12/1/92, 12/31/92 (Emer), 4/1/93, 12/29/95 (Emer), 3/21/96, 12/31/08 (Emer)

5160-4-16 Cardiovascular diagnostic and therapeutic services.

(A) Cardiovascular diagnostic and therapeutic (D and T) services are procedures listed in the 90000 code range of the current procedural terminology (CPT), and are for the diagnosis and treatment of cardiovascular system disorders.

(B) Refer to rule 5101:3-4-11 of the Administrative Code and appendix DD to rule 5101:3-1-60 of the Administrative Code for appropriate usage of the professional and/or technical modifiers and relevant place of service restrictions.

(C) All cardiovascular diagnostic and therapeutic procedures, including electrocardiogram interpretations, may be billed with evaluation and management services when appropriate in accordance with rule 5101:3-4-06 of the Administrative Code.

Replaces: 5101:3-4-16

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
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 Gastroenterology, otorhinolaryngology, endocrinology, neurology, photodynamic therapy and special dermatology services.

(A) The appropriate use of professional and technical modifiers and relevant place of service restrictions for gastroenterology, otorhinolaryngology, endocrinology, neurology, photodynamic therapy, and special dermatology procedures are set forth in rule 5101:3-4-11 of the Administrative Code.

(B) Otorhinolaryngologic services.

(1) The following speech and hearing services are professional services and may not be reimbursed in addition to an evaluation and management service:

(a) Otorhinolaryngologic examination under general anesthesia;

(b) Binocular microscopy performed as a separate procedure;

(c) Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status;

(d) Individual treatment of speech, language, voice, communication, and/or auditory processing disorder, including aural rehabilitation;

(e) Group treatment of speech, language, voice, communication, and/or auditory processing disorder, including aural rehabilitation;

(f) Nasopharyngoscopy performed as a separate procedure;

(g) Nasal function studies;

(h) Facial nerve function studies;

(i) Laryngeal function studies;

(j) Tympanometry and reflex threshold measurements; and

(k) Treatment of swallowing dysfunction and/or oral function for feeding.

(2) Procedure codes 92613, 92615 and 92617 are bundled into the related surgical procedure and are not separately reimbursable.

(3) When audiologic procedures are provided in a hospital setting, the services are considered hospital services and reimbursement will be made only to the hospital.

(4) Professional services associated with audiologic function tests are included either in the evaluation and management codes or the procedures listed in paragraph (B)(1) of this rule.

(5) Hearing aid examination and selection services are covered as part of the dispensation of the hearing aid in accordance with Chapter 5101:3-10 of the Administrative Code and will not be reimbursed as a separate procedure.

(C) Special dermatological procedures. Physician services associated with 96900, 96910, 96911, and 96912 are considered a part of the evaluation and management service.

Replaces: 5101:3-4-17

Effective: 12/06/2010
R.C. 119.032 review dates: 12/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
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 Pulmonary services.

(A) Pulmonary services are categorized as:

(1) Ventilation/pulmonary management services;

(2) Technical services;

(3) Bundled services (services that are considered a part of another provided service); or

(4) Procedures composed of professional and technical components.

(B) Ventilation/pulmonary management

(1) Ventilation/pulmonary management services are physician professional services that are included in the physician's evaluation and management service (visit) and may not be billed in conjunction with the codes for critical care, evaluation and management, or consultation services.

(2) A physician may be reimbursed for professional services associated with the pulmonary management of a hospital inpatient over a twenty-four-hour period if the physician's primary responsibility is to manage the patient's pulmonary care, the physician is not the patient's primary or attending physician, and the physician is not billing a visit for the same date of service. For reimbursement, the provider must bill the appropriate code for pulmonary management services.

(3) Ventilation management includes:

(a) The initiation and maintenance of mechanical ventilation and controlled oxygen administration;

(b) The establishment of mechanisms necessary for the monitoring of the patient;

(c) The evaluation of all laboratory procedures used to determine ventilation treatment and/or diagnosis;

(d) The adjustment of treatment plan(s); and

(e) Maintenance of medical records.

(C) Professional services

Surfactant administration may not be billed in conjunction with critical care services codes.

(D) Bundled services

The interpretation of blood gases and noninvasive oximetry services are considered incidental services and are bundled into the services for which they are incidental (e.g., visits, ventilation management, surgery anesthesia services, pulmonary consultations or oxygen supplier services). Blood gas and invasive oximetry procedures performed by certified laboratories are reimbursable in accordance with Chapter 5101:3-11 of the Administrative Code.

(E) Pulmonary services composed of professional and technical services

(1) The department will recognize a professional and technical component for all pulmonary procedures not listed in paragraphs (B) to (D) of this rule.

(2) Professional and technical modifiers and associated place of service restrictions are set forth in the definition of "PCTC indicator" values contained within rule 5101:3-4-11 of the Administrative Code.

(3) Procedures that have a professional and technical component and the corresponding percentage splits for payment are set forth in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(F) Pulmonary consultation services must be billed in accordance with paragraph (E) of rule 5101:3-4-06 of the Administrative Code.

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, 5111.021
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

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 5101:3-4-11 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.

Replaces: 5101:3-4-20

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 9/1/89, 5/1/90, 4/1/92 (Emer), 7/1/92, 3/30/95

5160-4-21 [Effective until 1/1/2017] Anesthesia services.

(A) The department will reimburse a physician for general, regional, or supplementation of local anesthesia services (or monitored anesthesia care services as described in paragraph (I) of this rule) provided during a surgical or diagnostic procedure. Anesthesia services include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the basic monitoring procedures. ECG, temperature, blood pressure, oximetry, capnography and mass spectometry are considered usual monitoring procedures. Unusual monitoring procedures such as intra-arterial, central venous and Swan Ganz are not included in the payment for anesthesia services and may be separately billed and reimbursed.

(B) Reimbursement for anesthesia services is the lesser of the provider's billed charge or the medicaid maximum payment as specified in paragraph (J)(5) of rule 5101:3-1-60 of the Administrative Code for services provided before May 1, 2001. For services provided on or after May 1, 2001, reimbursement for anesthesia services will be the amount obtained using the following formula:

Except for the exceptions set forth in paragraph (B) (7) of this rule, the formula for calculating the reimbursement of anesthesia services will be the base unit value and the time unit value multiplied by the appropriate conversion factor or percentage of a conversion factor as set forth in rule 5101:3-4-21.2 of the Administrative Code.

(1) "Base unit" means the value for each anesthesia code that reflects all activities other than anesthesia time. Anesthesia activities include usual pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia care, and monitoring services.

(2) "Base unit value" means the value for a base unit for each anesthesia code. These values are taken from the 200001/01/2007 American society of anesthesiologists' relative value guide. For purposes of medicaid reimbursement, base unit values from the American society of anesthesiologists will be used for anesthesia codes. For any anesthesia code covered by the department, the department will use the base unit value assigned by the American society of anesthesiologists for the year that the code was added.

(3) "Time unit" means the continuous actual presence of the physician (or of the medically-directed resident or medically-directed CRNA/AA) and starts when he/she begins to prepare the patient for anesthesia and ends when the anesthesiologist (or medically-directed CRNA/AA) is no longer in personal attendance with the exception of anesthesia for neuraxial analgesia for obstetrical services defined in paragraph (C) of rule 5101:3-4-21.1 of the Administrative Code.

(4) "Anesthesia time" is the actual number of anesthesia minutes as reported on the claim. Anesthesia time is defined in paragraph (D) (3) of this rule.

(5) "Time unit value" means one unit for each fifteen minutes of reported anesthesia time. Since only the actual time of a fractional time unit is recognized, the resulting time unit value will be rounded to one decimal place.

(6) Anesthesia conversion factors are specified in rule 5101:3-4-21.2 of the Administrative Code.

(7) The following formula exceptions apply:

(a) Anesthesia code 01996 will be paid based on the base units specified in the relative value guide. No calculation for time is allowable for this anesthesia code; and

(b) Services billed with the "AD" modifier will be paid at three times the conversion factor set forth in rule 5101:3-4-21.2 of the Administrative Code.

(C) The department will reimburse a physician for anesthesia services only if all of the following conditions are met.

(1) Except as provided for in paragraph (C)(5) of this rule, the physician is acting exclusively as an anesthetist and is not also acting as the surgeon or assistant surgeon;.

(2) For each patient, the physician:

(a) Performs a pre-anesthetic examination and evaluation;

(b) Prescribes the anesthesia plan;

(c) Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;

(d) Ensures that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual;

(e) Monitors the course of anesthesia administration at frequent intervals;

(f) Remains physically present and available for immediate diagnosis and treatment of emergencies; and

(g) Provides indicated post-anesthetic care.

(3) The physician either personally performs the services itemized in paragraph (C)(2) of this rule, without the assistance of a CRNA/AA, resident, intern, fellow, or other qualified anesthetist; or the physician uses assistance of a CRNA/AA, resident, intern, fellow or other qualified anesthetist in the performance of the services in paragraph (C)(2) of this rule, and does not perform any other services while providing medical direction.

(a) "Medical direction" is when a physician meets the requirement set forth in paragraph (C) (1) of this rule and the physician utilizes the assistance of a CRNA/AA, resident, intern, or fellow in the performance of the services listed in paragraph (C) (2) of this rule and is involved in no more than four concurrent anesthesia cases;.

(b) "Medical supervision" is when the physician meets the requirement set forth in paragraphs (C)(1), (C)(2)(a) and (C)(2)(b) of this rule and the physician anesthesiologist is involved in furnishing services for more than four concurrent procedures or is performing other services while directing the concurrent procedures.

(4) In situations where the physician is involved in medically supervising more than four procedures concurrently, or is performing other services while directing the concurrent procedures, the physician must be involved in the pre-surgical anesthesia services.

(5) When a surgeon or a group practice of surgeons employs CRNA to provide anesthesia services, the physician or group practice may bill and receive reimbursement for the services of the CRNA in addition to the reimbursement for the surgical procedures performed by the physician.

(D) For reimbursement the physician must bill the appropriate anesthesia code for the service provided modified by the appropriate anesthesia modifier, and report the anesthesia time in minutes.

(1) The following anesthesia modifiers must be used for billing anesthesia services:

AA Anesthesia services personally performed by the anesthesiologist;

AD Medical supervision by a physician: more than four concurrent anesthesia procedures;

QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals;

QX CRNA with medical direction by a physician or anesthesia assistant with medical direction by an anesthesiologist;

QY Medical direction of one CRNA by an anesthesiologist; and

QZ CRNA without medical direction by physician.

Note: Anesthesiologist assistants may use the modifier "QX" to bill for services provided under the medical direction of an anesthesiologist if they are employed by a physician or in an independent practice. An anesthesiologist may bill the "QY" modifier if he/she provides medical direction to an anesthesiologist assistant.

(2) Except as provided for in paragraph (H) of this rule, reimbursement for the services of a CRNA/AA may not be made to a provider of physician services, including hospitals.

(a) Services of a hospital employed CRNA/AA are included in the facility payment made to the hospital.

(b) Services of a self-employed CRNA/AA or a CRNA/AA who is a member of an independent CRNA/AA group practice is reimbursable directly to the CRNA/AA or CRNA/AA group practice.

(3) Anesthesia time begins when the anesthetist begins to prepare the patient for the induction of anesthesia in the operating room or in an equivalent area and ends when the anesthetist is no longer in personal attendance, that is, when the patient may be safely placed under post-anesthetic supervision.

(4) The modifier "AA" may be used if a teaching anesthesiologist is continuously involved in one procedure with one resident or with one student certified registered nurse anesthetist. The teaching anesthesiologist must document in the medical records that he or she was present during all critical portions of the procedure including induction and emergence.

(5) A physician who provides medical direction of a CRNA/AA may submit claim(s) for medical direction of a CRNA/AA as described in paragraph (H)(3) of this rule.

(E) No additional reimbursement will be paid for the physical status of the patient, the age of the patient, body hypothermia, body hyperthermia, emergency conditions, or time of day.

(F) When it is medically necessary to provide general anesthesia services for extensive restorative dental procedures or for a medicaid covered oral surgery procedure for which there is not a surgical code, the anesthesia services must be billed using code 00170 modified by the appropriate anesthesia modifier.

(G) For the reimbursement of anesthesia services the physician must bill the anesthesia code that best describes the anesthesia procedure performed modified by the appropriate anesthesia modifier as listed in paragraph (D) of this rule, and report the total anesthesia time in minutes.

(1) Except as provided for in paragraph (G)(2) of this rule, when anesthesia services are provided for more than one surgical procedure performed on the same date of service for the same patient, the department will reimburse for only one anesthesia service. Reimbursement will be based on the appropriate anesthesia code and the total anesthesia time reported should be inclusive of the anesthesia time encompassing all of the surgical procedures.

(2) The department will pay for two anesthesia services provided on the same patient on the same date of service on a case-by-case basis only if one or more of the following conditions apply:

(a) The patient was either discharged from the hospital or was released from the recovery/surgical area to the floor or surgical intensive care unit;

(b) The patient had to return to the operating room on an emergency basis;

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

(d) The patient had anesthesia for a vaginal delivery of a newborn and anesthesia for a tubal ligation procedure meeting the requirements specified in rule 5101:3-21-01 of the Administrative Code performed separately on the same day.

(H) Reimbursement will be made to a provider of physician services for CRNA/AA services under the following conditions:

(1) When the CRNA/AA is employed by a physician, hospital, , or other valid provider of physican services and the claim is for the medicare coinsurance and deductible amounts due for medicare covered CRNA/AA services provided to a patient who is dually eligible for medicare and medicaid, even if separate reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g., hospital-employed CRNA/AA services).

(a) The coinsurance and deductible payments should normally be made through the automatic crossover mechanism.

(b) If the claims for the anesthesia services provided by the CRNA/AA did not get paid through the automatic crossover system, the provider must submit a medicaid crossover claim, in accordance with the crossover billing instructions specified in BIN.1101 except that the CRNA/AA's medicaid legacy number must be submitted as the rendering provider and the employing provider's medicaid legacy number must be submitted as the "pay to" provider.

(c) If the claims for the anesthesia services provided by the CRNA/AA were paid but the claims for the anesthesia services provided by the physician were denied through the automatic crossover system, the provider must submit a medicaid crossover claim, with the physician's medicaid legacy number listed as the rendering provider. If it is a physician group practice the medicaid legacy number for the group practice must be submitted as the "pay to" provider.

(2) When the CRNA is employed by the surgeon. In such cases, the services of the CRNA must be billed on a separate physician claim form from the surgeon and the medicaid legacy number and national provider indentifier number (NPI) of the CRNA must be listed as the rendering provider and the medicaid legacy number and the NPI number of the employing physician or the physician group practice must be listed as the "pay to" provider.

(3) When a CRNA/AA is employed by a physician acting exclusively as an anesthetist as specified in paragraph (C) (1) of this rule or an anesthesiology group practice.

(a) One claim must be submitted when no medical direction or supervision was provided by the physician/anesthesiologist.

(b) Two claims must be submitted when the physician/anesthesiologist meeting the requirement in paragraph (C) (1) of this rule provides medical direction or medical supervision to CRNAs/AAs.

(i) On one claim the physician/anesthesiologist who provided the medical direction would be listed as the rendering provider and the anesthesia code for the anesthesia procedure modified by the appropriate modifier indicating medical direction listed in paragraph (D) (1) of this rule should be billed.

(ii) On the second claim for services provided by the CRNA/AA, the CRNA/AA who provided the service under the medical direction of a physician would be listed as the rendering provider and the physician providing the medical direction would be listed as the "pay to" provider. The appropriate anesthesia code must be modified by "QX" to denote a CRNA/AA under the medical direction of a physician.

(I) Monitored anesthesia care (MAC) is a combination of local anesthesia and certain anxiolytic and analgesic medications. When this type of anesthesia is used, the patient maintains protective reflexes and consciousness except for a brief period of time. Monitored anesthesia care requires the same expertise and work as required in the delivery of general anesthesia. Billing and reimbursement for monitored anesthesia care is the same as for general anesthesia when all of the conditions for reimbursement listed in paragraph (C) of this rule are met. There is no additional reimbursement for monitored anesthesia.

Click to view Appendix

Effective: 11/20/2007
R.C. 119.032 review dates: 08/30/2007 and 11/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
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, 5/2/94 (Emer), 6/3/94 (Emer), 7/24/94, 3/30/95, 12/31/96 (Emer), 3/22/97, 1/1/00, 5/1/01, 9/1/02

5160-4-21 [Effective 1/1/2017] 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

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, 01/04/2000, 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 [Effective until 1/1/2017] Anesthesia for neuraxial analgesia for obstetrical services.

(A) This rule applies to the following obstetrical care anesthesia procedures:

(1) Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or necessary replacement of an epidural catheter during labor); and

(2) Anesthesia for cesarean delivery following Neuraxial neuraxial analgesia/anesthesia.

(B) All of the provisions of rule 5101:3-4-21 of the Administrative Code apply to anesthesia services for the obstetrical anesthesia listed in paragraph (A) of this rule, except for:

(1) Paragraph (B)(3) of rule 5101:3-4-21 of the Administrative Code, which defines"time unit";

(2) Paragraph (C)(2) of rule 5101:3-4-21 of the Administrative Code;

(3) Paragraph (C)(4) of rule 5101:3-4-21 of the Administrative Code; and

(4) Paragraph (D)(3) of rule 5101:3-4-21 of the Administrative Code.

(C) In the case of anesthesia for obstetrical services listed in paragraph (A) of this rule, "time unit" shall be defined as "time begins when the neuraxial labor analgesic is inserted and continues through delivery."Time for obstetrical anesthesia is the lower of actual time from insertion through delivery or a maximum of four hours.

(D) The department will reimburse for neuraxial analgesia for obstetrical services if the following conditions are met:

(1) For each patient, the physician, must:

(a) Perform or approve a pre-anesthesia examination and evaluation for labor analgesia performed by a qualified anesthesia provider;

(b) Prescribe or approve an anesthesia plan;

(c) Personally participate in all critical portions of the procedure, including placement of the epidural or other regional technique;

(d) Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified anesthesia provider;

(e) Periodically monitor the course of anesthesia/analgesia administration or ensure that a qualified anesthesia provider performs the monitoring;

(f) Remain readily available for immediate diagnosis and treatment of emergencies as required by Ohio statute; and

(g) Provide indicated post-anesthesia care.

(2) If medical supervision is provided for neuraxial analgesia and the "AD" modifier is billed, the physician must be involved in the pre-procedure anesthesia services.

(a) Medical supervision applies to labor analgesia services when:

(i) The anesthesiologist is supervising more than four concurrent surgical anesthesia procedures while supervising a critical portion, e.g., epidural placement of a labor analgesia technique;

(ii) The anesthesiologist is supervising more than four epidural placements at the same time; or

(iii) The anesthesiologist is not in the obstetrical suite while supervising the critical portion of of the neuraxial technique.

(b) Paragraph (D)(1)(c) of this rule does not apply to medically- supervised labor analgesia services.

(E) In the event that anesthesia for surgery is required during the course of a labor analgesic technique, i.e., cesarean section, the provisions outlined in paragraph (C) of rule 5101:3-4-21 of the Administrative Code apply.

Effective: 10/01/2006
R.C. 119.032 review dates: 06/15/2006 and 10/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 1/01/02

5160-4-21.1 [Rescinded effective 1/1/2017] Anesthesia for neuraxial analgesia for obstetrical services.

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 [Effective until 1/1/2017] Anesthesia conversion factors.

(A) For modifiers "AA", "AD", or "QZ", the conversion factor is fifteen dollars and twenty-eight cents for dates of service between May 1, 2001 and December 31, 2009. For dates of service dates of service on or after January 1, 2010, the conversion factor is fourteen dollars and eighty-two cents.

(B) For modifiers "QK", QX", or "QY", the conversion factor is sixteen dollars and twenty-six cents for dates of service between September 1, 2002 and December 31, 2009. For dates of service on or after January 1, 2010, the conversion factor is fifteen dollars and seventy-seven cents.

2002.

(C) Services billed with the "QK", "QX", or "QY" modifiers described in paragraph

(D)

(1) of rule 5101:3-4-21 of the Administrative Code will be reimbursed at fifty per cent ofthe conversion factor stated in paragraph (B) ofthis rule.

Effective: 01/01/2010
R.C. 119.032 review dates: 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02, Section 309.30.75 of Am. Sub. H.B. 1, 128th
G.A
Rule Amplifies: 5111.01, 5111.02, 5111.021, Section 309.30.75 of
Am. Sub. H.B. 1, 128th G.A
Prior Effective Dates: 9/1/02, 9/1/05

5160-4-21.2 [Rescinded effective 1/1/2017] Anesthesia conversion factors.

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

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

(ii) In assigning procedures to these groups, the department follows the policies of the medicare program.

(2) 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.

(3) Payment for the surgical treatment of obesity requires prior authorization.

(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 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 bilateral procedure, one hundred fifty per cent; or

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

Replaces: 5160-4-22

Click to view Appendix

Effective: 7/3/2015
Five Year Review (FYR) Dates: 07/03/2020
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, 12/18/13 (Emer), 3/27/14, 12/31/14 (Emer)

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

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 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 5160-11 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 5160-1-60 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 radiological 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 5160-1-60 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 is the lesser of the provider's submitted charge or:

(i) For the total procedure, the maximum fee listed in appendix DD to rule 5160-1-60 of the Administrative Code;

(ii) For the professional component, the maximum fee listed in appendix DD to rule 5160-1-60 of the Administrative Code multiplied by the percentage indicated by the code for the professional component; or

(iii) For the technical component, the maximum fee listed in appendix DD to rule 5160-1-60 of the Administrative Code multiplied by the percentage indicated by the code for the technical component.

(c) If more than one advanced imaging procedure (CT, MRI, or ultrasound) is performed by the same provider or provider group for an individual patient in the same session, then the procedure with the highest fee specified in appendix DD to rule 5160-1-60 of the Administrative Code is considered to be the primary procedure. The maximum fee for a radiology procedure is the lesser of the provider's 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:

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

(ii) For each additional global or technical component of a procedure, it is fifty per cent.

(iii) For each additional professional component of a procedure, it is seventy-five per cent.

(d) 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 radiological 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 5160-1-60 of the Administrative Code for supplies for radiological procedures performed in a non-hospital setting.

(b) Codes for supplies for radiological 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 centers (FQHCs);

(vi) Hospitals; and

(vii) Independent diagnostic testing facilities (IDTFs).

Effective: 07/31/2014
R.C. 119.032 review dates: 05/12/2014 and 07/31/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
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

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

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

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.

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.

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 Coverage of extra -corporeal -membrane -oxygenator (ECMO) services.

(A) A physician may be reimbursed for the professional services associated with ECMO treatments for patients that meet the criteria for ECMO as set forth by the hospital where the service is performed. The hospital's criteria for ECMO must be consistent with acceptable medical practices .

(B) The department will not cover ECMO treatments performed for conditions for which the efficacy has not been established and the treatments have not been accepted as standard medical practice for the patient's condition. ECMO under these circumstances will be considered an experimental procedure. In general, ECMO is indicated for any cardiac and/or pulmonary condition (whether congenital or acquired) that is unresponsive to conventional therapy with a high likelihood of morbidity and/or mortality without ECMO.

(C) The physician who inserts the cannula for the ECMO procedure and initiates the ECMO treatment may be reimbursed for these services by billing current procedural terminology (CPT) code 36822. This procedure will be paid in addition to CPT code 33960 as noted in paragraph (I) of this rule.

(D) Reimbursement is available for professional services associated with the maintenance and management of ECMO treatments provided over a twenty-four-hour period.

(E) Except as provided for in paragraph (F) of this rule, reimbursement for evaluation and management services, including newborn critical care services, are bundled into the reimbursement for ECMO.

(F) Reimbursement is available for evaluation and management services, including newborn critical care services, provided prior to the initiation of ECMO treatments.

(G) Reimbursement is available for diagnostic, therapeutic, and surgical services that are not integral to ECMO treatment but are personally provided by the physician during the treatment .

(H) For the supervising physician to be entitled to reimbursement when residents, interns, or fellows are involved in the management of a patient during an ECMO treatment, the medical records must demonstrate that the supervising physician was personally present in the unit with sufficient regularity during the twenty-fourhour period that it could be concluded that the supervising physician was personally responsible for the patient's care during the ECMO treatment.

(I) Providers should bill CPT code 33960 for the first twenty-four hours and 33961 for each additional twenty-four hours.

Regardless of the number of providers, no more than twenty-four hours of ECMO services shall be reimbursed during a twenty-four hour period.

Effective: 04/25/2011
R.C. 119.032 review dates: 01/12/2011 and 04/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
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

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 Preventive medicine services.

(A) Preventive medicine is that part of medicine engaged with preventing disease and the maintenance of good health practices. The purpose of preventive medicine is to take a proactive approach to avoiding disease, disability, and death.

(B) Medicaid-covered preventive medicine services may include, but are not necessarily limited to:

(1) Routine infant checkups;

(2) All healthchek (EPSDT) services in accordance with Chapter 5101:3-14 of the Administrative Code;

(3) Immunizations in accordance with rule 5101:3-4-12 of the Administrative Code;

(4) Gynecologic examinations that include pelvic and breast examinations, and pap smears;

(5) Pregnancy prevention/contraceptive management visits and services in accordance with rule 5101:3-21-02 of the Administrative Code;

(6) Pregnancy-related services in accordance with rule 5101:3-21-04 of the Administrative Code;

(7) Mammography services in accordance with rule 5101:3-4-25 of the Administrative Code;

(8) Required physicals for employment or for participation in job training programs, when the employer does not provide a physical free of charge or when other available funds do not pay for an employment physical. Documentation to support that the physical was performed for employment must be in the patient's medical records .

If the recipient is over age twenty, providers should bill the proper office visit code (not preventive visit code);

(9) The required physician visits and annual chest x-rays for long term care facility (LTCF) residents;

(10) Required annual physical examinations for individuals living in residential facilities licensed by the Ohio department of mental retardation and developmental disabilities. This annual examination is not required for those individuals who are receiving ongoing medical services from a licensed physician;

(11) Prostate cancer screening tests;

(12) Glaucoma screening in accordance with Chapter 5101:3-06 of the Administrative Code;

(13) Screening colonoscopies for individuals age fifty or older or for high-risk patients. "High risk" is defined in "Your Guide to Medicare's Preventive Services," (01/2009) which can be found at http://www.medicare.gov/publications/pubs/pdf/10110.pdf. A physician must perform the screening ;

(14) Screening and counseling for obesity provided during an evaluation and management or preventive medicine visit;

(15) Medical nutritional therapy

(a) When medical nutritional services are provided by a registered dietician, providers should do the following:

(i) Use the medical nutrition therapy codes 97802 to 97804;

(ii) Use the AE modifier; and

(iii) Bill under the national provider identifier (NPI) of the supervising physician, physician assistant, or advanced practice nurse.

(b) When medical nutritional services are provided by a physician or physician assistant, providers should use the appropriate evaluation and management or preventive medicine code.

(c) When medical nutritional services are provided by an advanced practice nurse, providers should use either the medical nutrition therapy code or the appropriate evaluation and management or preventive medicine code; and

(16) Tobacco cessation counseling (99406 and 99407) and classes (S9453) are covered for the following populations:

(a) Pregnant women; and

(b) Children under the age of twenty-one.

Effective: 12/22/2011
R.C. 119.032 review dates: 07/01/2014
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, 7/1/80, 10/1/87, 9/1/89, 4/1/92 (Emer), 7/1/92, 7/1/93, 1/4/00 (Emer), 3/20/00, 12/31/01 (Emer), 3/9/02, 12/30/05 (Emer), 3/27/06, 11/13/06, 7/1/09

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.

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.

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