5160-4-11 Diagnostic and therapeutic procedures.

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

(B) PCTC indicator policy:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Replaces: 5101:3-4-11

Effective: 08/02/2011
R.C. 119.032 review dates: 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02
Prior Effective Dates: 4/1/92 (Emer), 7/1/92, 12/31/92 (Emer), 4/1/93, 12/30/93 (Emer), 3/31/94, 5/2/94 (Emer), 7/1/94, 1/1/01