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

Click to view Appendix

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 Supervision of professional services.

(A) Definitions.

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

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

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

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

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

(B) Coverage.

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

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

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

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

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

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

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

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

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

(C) Limitations and exceptions.

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

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

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

Replaces: 5160-4-02

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

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

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

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

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

Replaces: 5101:3-4- 02.1

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

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

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

5160-4-03 Physician assistants.

(A) Definitions.

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

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

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

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

(B) Eligible providers.

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

(C) Coverage and limitations.

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

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

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

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

(D) Claim payment.

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

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

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

Replaces: 5160-4-03

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

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

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

(B) Coverage.

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

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

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

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

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

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

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

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

(C) Claim payment.

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

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

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

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

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

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

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

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

(A) Definitions.

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

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

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

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

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

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

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

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

(iii) Preventive medicine visit, new patient;

(iv) Preventive medicine visit, established patient; or

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

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

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

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

(a) Family practice;

(b) General internal medicine;

(c) Pediatrics;

(d) Obstetrics and gynecology; or

(e) Geriatric medicine.

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

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

Replaces: 5160-4-05

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 [Rescinded] Covered obstetrical services.

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

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

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

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

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

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

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

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

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

Replaces: 5160-4-11

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

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 services provided by medical practitioners.

(A) Routine maintenance dialysis.

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

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

(a) The declotting of shunts; and

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

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

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

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

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

(i) More than one monthly capitation payment ;

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

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

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

(B) Inpatient dialysis services.

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

(a) For acute renal failure or renal trauma;

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

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

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

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

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

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

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

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

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

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

5160-4-18 [Rescinded] Pulmonary services.

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

5160-4-19 Allergy services.

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

(B) Coverage.

(1) Allergy testing.

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

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

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

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

(2) Ingestion challenge testing.

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

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

(3) Allergen immunotherapy.

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

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

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

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

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

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

Replaces: 5160-4-19

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

5160-4-20 Chemotherapy treatment.

(A) Provision of the chemotherapeutic agent.

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

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

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

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

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

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

5160-4-21 Anesthesia services.

(A) Scope and definitions.

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

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

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

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

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

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

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

(B) Providers.

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

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

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

(c) An anesthesiologist assistant (AA).

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

(a) An anesthesiologist;

(b) A CRNA;

(c) A professional medical group; or

(d) An AA.

(C) Coverage.

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

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

(i) Administration of general anesthesia;

(ii) Administration of regional anesthesia;

(iii) Supplementation of local anesthesia;

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

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

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

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

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

(ii) Anesthesia for cesarean delivery; and

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

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

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

(b) Anesthesia care during the procedure;

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

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

(D) Allowances and limitations.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(v) Providing indicated post-anesthetic care.

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

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

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

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

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

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

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

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

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

(E) Claim payment.

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

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

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

(ii) The appropriate conversion factor; and

(iii) The relevant multiplier.

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

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

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

Replaces:

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

Click to view Appendix

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

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

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

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

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 Radiology and imaging services.

(A) Coverage.

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

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

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

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

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

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

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

(3) Professional component.

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

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

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

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

(4) Mammography services.

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

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

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

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

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

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

(B) Claim payment.

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

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

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

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

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

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

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

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

Replaces: 5160-4-25

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

5160-4-26 Physical medicine and rehabilitation services.

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

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

Replaces: Part of 5160-4-26

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