5160-4-29 Services provided for the diagnosis and treatment of mental and emotional disorders.

(A) Definitions.

(1) For the purpose of this rule, "direct supervision and general supervision" by a physician are defined in rule 5101:3-4-02 of the Administrative Code.

(2) "Clinical social worker (CSW)" is defined in rule 5101:3-16-01 of the Administrative Code.

(3) "Licensed social worker" is defined in section 4757.28 of the Revised Code;

(4) "Professional counselor" is as defined in rule 4757-3-01 of the Administrative Code; and

(5) "Professional clinical counselor" is as defined in rule 4757-3-01 of the Administrative Code.

(6) "Non-physician" as used in this rule means either a clinical social worker, licensed social worker, professional counselor, professional clinical counselor, or clinical psychologist.

(B) Covered clinical psychiatric diagnostic services, evaluative procedures and therapeutic procedures personally provided by a physician are directly reimbursable to the physician, regardless of the place of service.

(C) Services for the diagnosis and treatment of mental and emotional disorders are covered as physician services when the services are performed by a licensed social worker, professional counselor, or professional clinical counselor who is employed by or under contract with the physician or clinic as long as the services provided are within the licensed social worker's professional counselor's, or professional clinical counselor's scope of practice as defined in Chapter 4757. of the Revised Code and:

(1) The services performed by a clinical social worker are provided under the general supervision of a physician;

(2) The services performed by a licensed social worker who does not meet the requirements of a clinical social worker are provided;

(a) Under the direct supervision of a physician; or

(b) Under the general supervision of a physician and the direct supervision of a clinical social worker.

(3) The services performed by a professional counselor are provided under the direct supervision of a physician as described in rule 5101:3-4-02 of the Administrative Code;

(4) The services performed by a professional clinical counselor are provided under the general supervision of a physician as described in rule 5101:3-4-02 of the Administrative Code.

(D) A licensed social worker, a clinical social worker, professional counselor or professional clinical counselor may not be directly reimbursed for services provided under the medicaid program. Services of a licensed social worker, clinical social worker, professional counselor or professional clinical counselor may only be billed by and reimbursed to the employing or contracting physician or clinic only when the following provisions are met:

(1) The supervision requirements listed in paragraph (C) of this rule have been met; and

(2) The physician provides supervision which, at a minimum, includes the following:

(a) Discussion about the progress of the patient toward specified goals;

(b) Updating treatment plans as needed; and

(c) Periodic participation in therapy sessions.

Countersigning the therapist's signature is insufficient evidence of active supervision.

(E) Physicians or clinics may not be reimbursed for services provided by a licensed social worker clinical social worker, professional counselor or professional clinical counselor if the services are provided to patients in the inpatient hospital setting, in the outpatient hospital setting, or to resident of a LTCF.

(1) Services provided by a licensed social worker CSW, professional counselor or professional clinical counselor to patients in the inpatient or outpatient hospital setting are covered as hospital services in accordance with Chapter 5101:3-2 of the Administrative Code and may not be reimbursed separately.

(2) Services provided by a licensed social worker CSW, professional counselor or professional clinical counselor to residents of a long-term care facility are covered only as long-term care facility services in accordance with Chapter 5101:3-3 of the Administrative Code.

(F) The following services are noncovered under the medicaid program:

(1) Services provided in facilities regulated by the state board of education;

(2) Sensitivity training, encounter groups or workshops;

(3) Sexual competency training;

(4) Marathons and retreats for mental disorders; and

(5) Educational activities, testing and diagnosis;

(6) Monitoring activities of daily living;

(7) Recreational therapy (art, play, dance, or music);

(8) Teaching grooming skills;

(9) Services primarily for social interaction, diversion, or sensory stimulation;

(10) Psychotherapy services are not covered if the patient's cognitive deficit is too severe to establish a relationship with the psychotherapist; and

(11) Family therapy psychotherapy involving training of family members or care givers if the purpose is the management of the patient.

(G) For reimbursement for services provided by , non-physicians meeting the criteria in paragraph (C) of this rule, the services must be billed using the following codes and modifiers:

(1) Billable codes and services:

(a) For individual therapy, bill the standard individual therapy codes specified in paragraphs (D) (1)(a)(i) to (D) (1)(a)(ii) and (D) (1)(a)(iv) of rule 5101:3-8-05 of the Administrative Code;

(b) For group therapy, bill the standard codes specified in paragraphs (D) (1)(b)(i) to (D) (1)(b)(iv) of rule 5101:3-8-05 of the Administrative Code.

(2) Modifiers to signify the level of educational training of a non-physician providing therapy services:

(a) If the non-physician providing the service is a clinical social worker, bill the appropriate code modified by "AJ" to signify that a clinical social worker provided the service.

(b) If the non-physician providing the service is a clinical psychologist, bill the appropriate code modified by "AH" to signify that a clinical psychologist provided the service.

(c) If the non-physician providing the service holds a doctoral degree and is not a clinical psychologist, bill the appropriate code modified by "HP" to signify a doctoral level trained professional.

(d) If the non-physician providing the service holds a master's degree and is not a clinical social worker, bill the appropriate code modified by "HO" to indicate a masters degree level trained professional.

(e) If the non-physician providing the service holds a bachelor's degree only, bill the appropriate code , modified by "HN " to signify that a bachelor's level clinical staff person provided the service.

(3) Reimbursement for therapy provided by a non-physician will be reimbursed at the following levels:

(a) For services provided by a clinical psychologist, services will be reimbursed as stated in paragraph (D) (1) of rule 5101:3-8-05 of the Administrative Code.

(b) For individual therapy provided by non-physicians except as described in paragraph (G)(3)(a) of this rule , services will be reimbursed at the lesser of the provider's billed charge or fifty per cent of the medicaid maximum for the individual therapy code.

(c) For group therapy services provided by non-physicians except as described in paragraph (G)(3)(a) of this rule, services will be reimbursed at the lesser or the provider's billed charge or fifty per cent of the medicaid maximum for the group therapy code.

(H) The patient's medical record must substantiate the nature of the services billed including:

(1) The medical necessity of the services billed;

(2) A treatment plan which is signed and dated by the physician prior to initiating therapy. The treatment plan shall include but is not limited to:

(a) Relevant medical and psychiatric diagnoses;

(b) Treatment goals;

(c) Type, duration, frequency of therapy services;

(d) Response to treatment on an on-going basis;

(e) Prognosis; and

(f) Evidence of sufficient cognitive ability to benefit from therapy.

(3) Any medications prescribed;

(4) Information regarding the patient's symptoms, functional impairment, type, duration, and frequency of treatment including dates of treatment sessions;

(5) The face-to-face time period spent with the patient;

(6) Test results, if applicable.

Effective: 03/28/2013
R.C. 119.032 review dates: 01/07/2003
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 2/17/91, 11/1/01, 10/1/03, 12/31/12(Emer)