5160-4-02 Scope of coverage.

(A) Definitions.

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

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

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

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

(C) Services performed under direct supervision

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

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

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

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

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

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

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

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

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

(D) Services performed under general supervision

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Effective: 07/01/2009
R.C. 119.032 review dates: 04/14/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , , 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 5/19/86, 7/1/87, 4/1/88, 9/1/89, 2/17/91, 4/1/92 (Emer), 7/1/92, 5/2/94 (Emer), 7/1/94, 1/1/01, 1/2/04 (Emer), 4/1/04, 2/16/09