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

(A) Site differentials.

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

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

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

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

(ii) A skilled nursing facility;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Effective: 12/31/2013
R.C. 119.032 review dates: 10/15/2013 and 12/31/2018
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03 , 5164.02 , 5164.70
Prior Effective Dates: 05/25/1991, 04/01/1992 (Emer), 07/01/1992, 05/02/1994 (Emer), 07/01/1994, 01/01/2001, 09/01/2005, 07/01/2008, 08/02/2011