5160-4-18 Pulmonary services.

(A) Pulmonary services are categorized as:

(1) Ventilation/pulmonary management services;

(2) Technical services;

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

(4) Procedures composed of professional and technical components.

(B) Ventilation/pulmonary management

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

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

(3) Ventilation management includes:

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

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

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

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

(e) Maintenance of medical records.

(C) Professional services

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

(D) Bundled services

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

(E) Pulmonary services composed of professional and technical services

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

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

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

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

Effective: 08/02/2011
R.C. 119.032 review dates: 09/20/2010 and 08/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 9/1/89, 5/25/91, 4/1/92 (Emer), 7/1/92, 12/30/94 (Emer), 3/20/95, 1/1/01, 10/1/04, 12/29/06 (Emer), 3/29/07