Chapter 5160-7 Podiatric Services

5160-7-01 Eligible providers of podiatric services.

(A) Definitions.

(1) A doctor of podiatric medicine is included within the definition of "physician" but only in respect to functions he or she is legally authorized to perform as defined in section 4731.51 of the Revised Code.

(2) "Podiatric physician" means an individual currently licensed under state of Ohio law or another state's law to practice podiatry.

(3) Interns and residents of podiatric medicine are explicitly excluded from the definition of "podiatric physician" and are covered as part of hospital services. This exclusion applies whether or not the intern or resident may be authorized to practice as a podiatric physician under the laws of the state in which services are performed. Residents having a staff or faculty appointment or designated as a fellow are also excluded from the definition of podiatric physician.

(4) "Podiatric group practice" means a professional association organized under Chapter 1785. of the Revised Code for the purpose of providing podiatric services.

(B) All podiatric physicians currently licensed to practice podiatry under sections 4731.51 to 4731.61 of the Revised Code are eligible to participate in Ohio's medicaid program and provide podiatric medicine services upon execution of an Ohio medicaid provider agreement.

(C) A professional association (podiatric medicine group practice) is considered eligible to participate in Ohio's medicaid program if it is an association organized under Chapter 1785. of the Revised Code for the purpose of providing podiatric medicine services.

(D) Podiatric physicians licensed under another state law to practice medicine and surgery are eligible to participate in Ohio's medicaid program and provide covered podiatric medicine services as long as:

(1) The services are rendered to eligible Ohio consumers in the state in which the provider is licensed to practice; and

(2) The provider of podiatric medicine services has a current valid provider agreement with the Ohio department of job and family services (ODJFS).

Effective: 11/04/2010
R.C. 119.032 review dates: 07/29/2010 and 11/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 12/30/77, 5/9/86, 2/1/90, 8/15/05

5160-7-02 Podiatric medicine: scope of coverage.

(A) Podiatric physicians may perform covered services (as defined in Chapter 5101:3-7 of the Administrative Code) which consist of the medical, mechanical and surgical treatment of ailments of the foot, the muscles and tendons of the leg governing the foot, and superficial lesions of the hand other than those associated with trauma. The podiatric physician may also treat the local manifestation of systemic disease as they appear in the hand and foot, but the consumer must be concurrently referred to an eligible prescriber for treatment of the systemic disease itself.

(B) Podiatric medicine services provided by non-physicians under the direct and general supervision of a podiatric physician are covered in accordance with rule 5101:3-4-02 of the Administrative Code.

(C) Hospital-based podiatric physicians and surgeons are covered in accordance with rule 5101:3-4-01 of the Administrative Code.

(D) Podiatric medicine services provided in a teaching setting are covered as set forth in paragraphs (A) to (D)(2), (E)(1) and (F) of rule 5101:3-4-05 of the Administrative Code.

(E) Podiatric medicine services provided in a long-term care setting are covered as detailed in rule 5101:3-3-19 of the Administrative Code.

(F) Podiatric medicine services provided by a physician assistant are covered in accordance with rule 5101:3-4-03 of the Administrative Code.

(G) By report services are covered in accordance with rule 5101:3-4-02.1 of the Administrative Code. In addition, a report must be provided documenting the following:

(1) Complete description of the services or procedures;

(2) Diagnosis, both preoperative and postoperative;

(3) Size, location, and number of lesions;

(4) Indication of primary, secondary, or tertiary procedure;

(5) The nearest similar current procedural terminology (CPT) code whenever possible;

(6) Estimated number of visits for follow-up; and

(7) Operative time.

Effective: 11/04/2010
R.C. 119.032 review dates: 07/29/2010 and 11/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 5/19/86, 9/1/89, 2/1/90, 3/22/01, 8/15/05

5160-7-03 Covered podiatric services and associated limitations.

(A) Visit limitations.

(1) Visits are covered in accordance with rules 5101:3-3-19 and rule 5101:3-4-06 of the Administrative Code.

(2) In addition, the following limitations apply:

(a) Reimbursable evaluation and management services shall be limited to the following CPT codes:

99201 to 99203

99211 to 99213

99221 to 99222

99231 to 99232

99238

99241 to 99243

99251 to 99253

99304 to 99328

99341 to 99342

99347 to 99348

(b) Reimbursement by the department is limited to one long term care facility (LTCF) visit per month.

(B) Therapeutic injections and prescribed drugs are covered in accordance with rule 5101:3-4-13 of the Administrative Code. In addition, vitamin B-12 injections for strengthening tendons, ligaments, or other components of the foot are not covered.

(C) Surgeries.

(1) Surgeries are covered in accordance with rules 5101:3-4-09, 5101:3-4-22 and 5101:3-4-23 of the Administrative Code.

(2) In addition, the following limitation applies: reimbursement for debridement of nails is limited to a maximum of one treatment within a sixty-day period.

(D) Laboratory services are covered in accordance with Chapters 5101:3-4 and 5101:3-11 of the Administrative Code.

(E) Radiology services.

(1) Radiology services are covered in accordance with Chapters 5101:3-4 and 5101:3-11 of the Administrative Code.

(2) In addition, the following radiology services are not covered as podiatric medicine services:

(a) Bilateral x-rays when only a unilateral condition or surgery is reported, unless documented as medically indicated;

(b) X-rays in excess of three views unless the necessity due to trauma or infection is fully documented;

(c) X-rays for soft tissues unless for reasons of infections which is fully documented;

(d) Postoperative x-rays unless there is bone involvement necessitating the surgical procedure or cases of suspected postoperative infections; and

(e) The use of x-rays or radium for therapeutic purposes.

(F) Physical medicine services.

(1) Physical medicine services are covered in accordance with Chapter 5101:3-8 of the Administrative Code.

(2) In addition, the following limitations apply:

(a) Reimbursement for physical medicine services provided within the scope of practice of podiatric medicine and surgery as specified in the Revised Code is limited to acute conditions only. For those recipients in which the disease has reached a chronic stage, reimbursement will be made only for the periods of acute exacerbation of the disease.

(b) Range of motion studies may not be billed separately from an examination of the foot, unless substantiated by a complete report.

(G) Medical supplies and durable medical equipment (DME).

(1) A podiatric physician may not be separately reimbursed for medical supplies and equipment (e.g., tape, dressing, or surgical trays) utilized in podiatrist's office, clinic, or patient's home during a podiatric visit.

(2) A podiatric physician may be reimbursed for medical supplies and medical equipment dispensed in the podiatric physician's office, clinic or patient's home for use in the patient's home, if the podiatric physician has a "supplies and medical equipment" category of service .

(3) The scope and extent of coverage for medical supplies and durable medical equipment, including orthopedic shoes and foot orthoses, are covered in Chapters 5101:3-4 and 5101:3-10 of the Administrative Code.

Effective: 11/04/2010
R.C. 119.032 review dates: 07/29/2010 and 11/01/2015
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, 5/9/86, 5/19/86, 9/1/89, 2/1/90, 4/1/92 (Emer), 7/1/92, 1/1/01, 8/15/05, 12/29/06 (Emer), 3/29/07

5160-7-04 Podiatric medicine: noncovered services.

(A) The following services are noncovered:

(1) All services exceeding the policies and limitations defined in Chapters 5101:3-4 and 5101:3-7 of the Administrative Code.

(2) Services determined by the department as not medically necessary as defined in Chapter 5101:3-1 of the Administrative Code.

(3) Services of a preventive nature.

(B) In addition, the following services are noncovered, unless a consumer has a localized infection or is under the care of an eligible prescriber for a metabolic disease such as diabetes mellitus, or another condition that may result in a circulatory impairment or desensitization in the legs or feet:

(1) Examinations and diagnostic services associated with routine foot care performed in the absence of a localized illness, symptoms or injury;

(2) Cutting or removal of corns and calluses;

(3) Nail trimming, cutting or clipping of nails not associated with nail surgery, unless a systemic condition is present such as metabolic, neurologic, or peripheral vascular disease that may require scrupulous foot care by a professional an eligible prescriber;

(4) Foot care provided for hygienic services;

(5) The treatment of uncomplicated, chronic foot conditions such as flat feet or a sublaxated structure in the foot; and

(6) Treatment of mycotic nails for an ambulatory and nonambulatory consumer unless the eligible prescriber attending the patient's mycotic condition documents that:

(a) There is clinical evidence of onychomycosis of the toenail; and

(b) The consumer has mycosis/dystrophy of the toenail causing secondary infection and/or pain that results or would result in marked limitation of ambulation and require the professional skills of a podiatrist podiatric physician.

Effective: 11/04/2010
R.C. 119.032 review dates: 07/29/2010 and 11/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 4/7/77, 5/19/86, 9/1/89, 2/1/90, 1/1/01, 8/15/05