Chapter 5160-8 Limited Practitioner Services

5160-8-01 [Rescinded] Eligible providers of limited practitioner services.

Cite as Ohio Admin. Code 5160-8-01

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 04/07/1977, 09/19/1977, 12/21/1977, 07/01/2002, 01/01/2008, 08/02/2011

5160-8-02 [Rescinded] Covered physical therapy services and limitations.

Cite as Ohio Admin. Code 5160-8-02

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 04/07/1977, 09/19/1977, 12/21/1977, 12/30/1977, 07/01/2002, 01/01/2008

5160-8-03 [Rescinded] Covered occupational therapy services and limitations.

Cite as Ohio Admin. Code 5160-8-03

Effective: 01/01/2014
R.C. 119.032 review dates: 10/15/2013
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 01/01/2008

5160-8-05 Mental health services-other licensed professionals.

(A) Scope. This rule sets forth provisions governing payment for mental health services provided by certain licensed professionals in non-institutional settings.

(1) A mental health service performed in an inpatient or outpatient hospital setting is treated as a hospital service, rules for which are set forth in Chapter 5160-2 of the Administrative Code.

(2) Payment for certain mental health services rendered to a resident of a long-term care facility (LTCF) is made to the LTCF through the facility per diem in accordance with Chapter 5160-3 or Chapter 5123:2-7 of the Administrative Code. A provider who renders such a mental health service must seek payment from the LTCF.

(3) Provisions governing payment for mental health services as the following service types are set forth in the indicated part of the Administrative Code:

(a) Cost-based clinic services, Chapter 5160-28; and

(b) Medicaid school program services, Chapter 5160-35.

(B) Definitions for the purposes of this rule.

(1) "Mental health service" is a service or procedure that is performed for the diagnosis and treatment of mental, behavioral, or emotional disorders by a licensed professional or under the supervision of a licensed professional. As it is used in this rule, the term includes neither psychiatry nor medication management.

(2) "Licensed psychologist" has the same meaning as in section 4732.01 of the Revised Code.

(3) "Independent practitioner" is a collective term used in this rule to designate the following persons who hold a valid license to practice in accordance with the indicated portion of the Revised Code:

(a) Licensed professional clinical counselor, section 4757.22 ;

(b) Independent social worker, section 4757.27 ; and

(c) Independent marriage and family therapist, section 4757.30.

(d) Licensed independent chemical dependency counselor, rule 4758-4-01 of the Administrative Code

(4) "Supervised practitioner" is a collective term used in this rule to designate the following persons who hold a valid license to practice in accordance with the indicated portion of the Revised Code:

(a) Licensed professional counselor, section 4757.23 ;

(b) Social worker, section 4757.28 ; and

(c) Marriage and family therapist, section 4757.30.

(d) Licensed chemical dependency counselor II, rule 4758-4-01 of the Administrative Code

(e) Licensed chemical dependency counselor III, rule 4758-4-01 of the Administrative Code

(5) "Supervised trainee" is a collective term used in this rule to designate the following individuals:

(a) Registered counselor trainee, defined in rule 4757-13-09 of the Administrative Code;

(b) Registered social work trainee, defined in rule 4757-19-05 of the Administrative Code;

(c) Marriage and family therapist trainee, defined in rule 4757-25-08 of the Administrative Code;

(d) Chemical dependency counselor assistant, defined in rule 4758-4-01 of the Administrative Code; and

(e) Doctoral psychology trainee, a person who is enrolled in or has earned a degree from a doctoral psychology program meeting requirements set forth in section 4732.10 of the Revised Code, is working under the supervision of a licensed psychologist, and has been assigned by the supervising psychologist a title appearing in rule 4732-13-03 of the Administrative Code, such as "psychology intern," "psychology fellow," or "psychology resident."

(6) "Independent practice" is a business arrangement in which a professional is not subject to the administrative and professional control of an employer such as an institution, physician, or agency. In particular, a professional working from an office that is located within an entity is considered to be in independent practice when both of the following conditions are met:

(a) The part of the entity constituting the office of the professional is used solely for that purpose and is separately identifiable from the rest of the facility; and

(b) The professional maintains a private practice (i.e., offers services to the general public as well as to the customers, residents, or patients of the entity), and the practice is not owned, either in part or in total, by the entity.

(C) Provider requirements.

(1) A licensed psychologist or independent practitioner must be enrolled in the medicaid program as an eligible provider, even if services are rendered under the supervision of an eligible provider.

(2) A licensed psychologist in independent practice or independent practitioner in independent practice who can participate in the medicare program either must do so or, if the practice is limited to pediatric treatment, must meet all requirements for medicare participation other than serving medicare beneficiaries.

(D) Coverage.

(1) Payment may be made for the following mental health services:

(a) Diagnostic evaluation, one unit of each;

(b) Psychological and neuropsychological testing;

(c) Assessment and behavior change intervention:

(i) Alcohol or substance (other than tobacco) abuse, structured assessment and brief intervention, fifteen to thirty minutes;

(ii) Alcohol or substance (other than tobacco) abuse, structured assessment and intervention, greater than thirty minutes;

(iii) Smoking and tobacco use cessation counseling, intermediate, greater than three minutes up to ten minutes; and

(iv) Smoking and tobacco use cessation counseling, intensive, greater than ten minutes; and

(d) Therapeutic services:

(i) Individual psychotherapy provided in the office, outpatient clinic, or home:

(a) Psychotherapy, thirty minutes with patient and/or family member;

(b) Psychotherapy, forty-five minutes with patient and/or family member;

(c) Psychotherapy, sixty minutes with patient and/or family member;

(d) Psychotherapy for crisis, first sixty minutes;

(e) Psychotherapy for crisis, each additional thirty minutes; and

(f) Interactive complexity (reported separately in addition to the primary procedure); and

(ii) Family or group psychotherapy for which the primary purpose is the treatment of the patient and not family members:

(a) Family psychotherapy without patient present;

(b) Family psychotherapy with patient present;

(c) Group psychotherapy;

(d) Multiple-family group psychotherapy; and

(e) Interactive complexity (reported separately in addition to the primary procedure, only when specific communication barriers complicate the delivery of service).

(2) Payment may be made to the following eligible providers for a mental health service rendered as indicated:

(a) To a physician, group practice, or clinic for a mental health service rendered by a licensed psychologist, independent practitioner, or supervised practitioner employed by or under contract with the physician, group practice, or clinic;

(b) To a physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice, or independent practitioner in independent practice for a mental health service personally rendered by that health care professional;

(c) To a physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice, or independent practitioner in independent practice for a mental health service rendered by a supervised practitioner under the supervision of that health care professional; or

(d) To a licensed psychologist in independent practice or independent practitioner in independent practice for a mental health service rendered by a supervised trainee if the following conditions are met:

(i) The professional responsible for the patient's care has face-to-face contact with the patient at the following intervals:

(a) A licensed psychologist, during the initial visit and not less often than once per quarter (or during each visit if visits are scheduled more than three months apart); and

(b) A independent practitioner, during each visit; and

(ii) The professional responsible for the patient's care reviews and updates the patient's medical record at least once after each treatment visit.

(3) The following coverage limits, which may be exceeded only with prior authorization, are established for mental health services provided to an individual in a non-institutional setting:

(a) For diagnostic evaluation, one date of service per benefit year per code, not on the same date of service as a therapeutic visit;

(b) For psychological or neuropsychological testing, a maximum of eight hours per benefit year; and

(c) For therapeutic visits, a maximum of twenty-four dates of service per benefit year. if a diagnostic evaluation is performed, twenty-five if no diagnostic evaluation is performed.

(E) Constraints.

(1) Every mental health service reported on a claim must be within the scope of practice of the licensed professional, with appropriate certificationa and/or training for the service, who renders or supervises it and must be performed in accordance with any supervision requirements established in law, regulation, statute, or rule.

(2) Neither a supervised practitioner nor a supervised trainee can be reported on a claim as the rendering provider.

(3) No payment will be made under this rule for the following items:

(a) Services that are rendered by an unlicensed individual other than a supervised trainee;

(b) Services that are provided in facilities regulated by the state board of education;

(c) Activities, testing, or diagnosis conducted for purposes specifically related to education;

(d) Services that are unrelated to the treatment of a specific mental health complaint but serve primarily to enhance skills or to provide general information, examples of which are given in the following non-exhaustive list:

(i) Encounter groups, workshops, marathon sessions, or retreats;

(ii) Sensitivity training;

(iii) Sexual competency training;

(iv) Recreational therapy (e.g., art, play, dance, music);

(v) Services intended primarily for social interaction, diversion, or sensory stimulation; and

(vi) The teaching or monitoring of activities of daily living (such as grooming and personal hygiene);

(e) Psychotherapy services if the patient cannot establish a relationship with the provider because of a cognitive deficit;

(f) Family therapy for the purpose of training family members or caregivers in the management of the patient; and

(g) Self-administered or self-scored tests of cognitive function.

(F) Documentation of services.

The patient's file must substantiate the medical necessity of services performed, and each record is expected to bear the signature and indicate the discipline of the professional who entered it. The following items must be included as documentation if applicable:

(1) A description of the patient's symptoms and functional impairment;

(2) All relevant diagnoses pertaining to medical or physical conditions as well as to mental health;

(3) Evidence that the patient has sufficient cognitive capacity to benefit from treatment;

(4) A treatment plan that specifies treatment goals, tracks responses to ongoing treatment, and presents a prognosis;

(5) The type, duration, and frequency of treatment, with dates of service;

(6) Medications taken by or prescribed for the patient;

(7) The amount of time spent by the provider face-to-face with the patient;

(8) The amount of time spent by the provider in interpreting and reporting on procedures represented by "Central Nervous System Testing" codes;

(9) Test results, if applicable, with interpretation;

(10) Summaries of psychotherapy sessions; and

(11) Any psychotherapy notes that are kept.

(G) Claim payment.

The payment amount for a mental health service is the lesser of the provider's submitted charge or the applicable percentage of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code:

(1) For testing, it is one hundred per cent;

(2) For a mental health service other than testing, the percentage differs according to the provider who rendered it:

(a) For a service rendered by a physician, an advanced practice registered nurse, a physician assistant, or a licensed psychologist, it is one hundred per cent; and

(b) For a service rendered by an independent practitioner or a supervised practitioner, it is eighty-five per cent.

Cite as Ohio Admin. Code 5160-8-05

Effective: 10/29/2016
Five Year Review (FYR) Dates: 08/12/2016 and 10/29/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 2/17/91, 11/1/01, 7/1/02, 8/17/03, 10/1/03, 1/1/04, 12/30/05 (Emer), 3/27/06, 1/1/08, 12/31/12 (Emer), 3/28/13, 1/1/14, 6/30/16, 2/1/2016

5160-8-11 Spinal manipulation and related diagnostic imaging services.

(A) Scope. This rule sets forth provisions governing payment for professional, non-institutional spinal manipulation and related diagnostic imaging services. Provisions governing payment for such services performed in a federally qualified health center are set forth in Chapter 5160-28 of the Administrative Code.

(B) Providers.

(1) Rendering providers. The following eligible providers may render a service described in this rule:

(a) A chiropractor (an individual who holds a valid license as a chiropractor under Chapter 4734. of the Revised Code and works within the scope of practice defined by state law); or

(b) A mechanotherapist (an individual who holds a valid license as a mechanotherapist under Chapter 4731. of the Revised Code and works within the scope of practice defined by state law).

(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for submitting a claim for a covered service on behalf of a rendering provider:

(a) A chiropractor;

(b) A mechanotherapist;

(c) A professional medical group, which is described in rule 5160-1-17 of the Administrative Code;

(d) A hospital, rules for which are set forth in Chapter 5160-2 of the Administrative Code; or

(e) A fee-for-service clinic, rules for which are set forth in Chapter 5160-13 of the Administrative Code.

(C) Coverage.

(1) Payment for manual manipulation of the spine may be made only for the correction of a subluxation, the existence of which must be determined either by physical examination or by diagnostic imaging. If the determination is made by physical examination, the following criteria must be met:

(a) At least one of the following two conditions exists:

(i) Asymmetry or misalignment on a sectional or segmental level; or

(ii) Abnormality in the range of motion; and

(b) At least one of the following two symptoms is present:

(i) Significant pain or tenderness in the affected area; or

(ii) Changes in the tone or characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

(2) Payment may be made only for the following services:

(a) Spinal manipulation.

(i) Chiropractic manipulative treatment (CMT); spinal, one to two regions.

(ii) Chiropractic manipulative treatment (CMT); spinal, three to four regions.

(iii) Chiropractic manipulative treatment (CMT); spinal, five regions.

(b) Diagnostic imaging to determine the existence of a subluxation.

(i) Spine, entire; survey study, anteroposterior and lateral.

(ii) Spine, cervical; anteroposterior and lateral.

(iii) Spine, cervical; anteroposterior and lateral; minimum of four views.

(iv) Spine, cervical; anteroposterior and lateral; complete, including oblique and flexion and/or extension studies.

(v) Spine, thoracic; anteroposterior and lateral views.

(vi) Spine, thoracic; complete, with oblique views; minimum of four views.

(vii) Spine, thoracolumbar; anteroposterior and lateral views.

(viii) Spine, lumbosacral; anteroposterior and lateral views.

(ix) Spine, lumbosacral; complete, with oblique views.

(x) Spine, lumbosacral; complete, including bending views.

(D) Requirements, constraints, and limitations.

(1) The following coverage limits, which may be exceeded with prior authorization, are established for the indicated services:

(a) Spinal manipulation, one treatment per date of service;

(b) Diagnostic imaging of the entire spine to determine the existence of a subluxation, two sessions per benefit year;

(c) All other imaging, two sessions per six-month period; and

(d) Visits in an outpatient setting, thirty dates of service per benefit year for an individual younger than twenty-one years of age, fifteen dates of service per benefit year for an individual twenty-one years of age or older.

(2) Payment will not be made under this rule for any of the following services:

(a) A service that is not medically necessary, examples of which are shown in the following non-exhaustive list:

(i) A service unrelated to the treatment of a specific medical complaint;

(ii) Treatment of a disease, disorder, or condition that does not respond to spinal manipulation, such as multiple sclerosis, rheumatoid arthritis, muscular dystrophy, sinus problems, and pneumonia;

(iii) Preventive treatment;

(iv) Repeated treatment without an achievable and clearly defined goal;

(v) Repeated imaging or other diagnostic procedure for a chronic, permanent condition;

(vi) Treatment from which the maximum therapeutic benefit has already been achieved and the continuation of which cannot reasonably be expected to improve the condition or arrest deterioration within a reasonable and generally predictable period of time; and

(vii) A service performed more frequently than the standard generally accepted by peers;

(b) A service that is performed by someone other than a chiropractor or mechanotherapist who is an eligible provider; and

(c) A service that is performed by a chiropractor or mechanotherapist who is an eligible provider but that is neither chiropractic manipulation nor diagnostic imaging to determine the existence of a subluxation, illustrated by the following examples:

(i) Diagnostic studies;

(ii) Drugs;

(iii) Equipment used for manipulation;

(iv) Evaluation and management services;

(v) Injections;

(vi) Laboratory tests;

(vii) Maintenance therapy (therapy that is performed to treat a chronic, stable condition or to prevent deterioration);

(viii) Manual manipulation for purposes other than the treatment of subluxation;

(ix) Orthopedic devices;

(x) Physical therapy;

(xi) Supplies; and

(xii) Traction.

Replaces: 5160-8-11

Cite as Ohio Admin. Code 5160-8-11

Effective: 5/8/2016
Five Year Review (FYR) Dates: 05/08/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 02/10/1986, 12/31/1996 (Emer), 03/22/1997, 07/01/2002, 01/01/2004, 01/01/2008

5160-8-20 [Rescinded] Advanced practice nurses.

Cite as Ohio Admin. Code 5160-8-20

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 03/01/1994 (Emer), 05/12/1994, 05/01/1997, 06/01/2002, 01/01/2008

5160-8-21 [Rescinded] Advanced practice nurses: eligible Ohio medicaid providers.

Cite as Ohio Admin. Code 5160-8-21

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 03/01/1994 (Emer), 05/12/1994, 05/01/1997, 06/01/2002, 01/01/2008, 08/02/2011

5160-8-22 [Rescinded] Advanced practice nurses practice arrangements and reimbursement.

Cite as Ohio Admin. Code 5160-8-22

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 4723.41 to 4723.50
Prior Effective Dates: 09/24/1983, 04/01/1988, 05/15/1989, 03/01/1994 (Emer), 05/12/1994, 05/01/1997, 06/01/2002, 01/01/2008

5160-8-23 [Rescinded] Advanced practice nurses: coverage and limitations.

Cite as Ohio Admin. Code 5160-8-23

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 4723.41 to 4723.50
Prior Effective Dates: 09/24/1983, 03/01/1994 (Emer), 05/12/1994, 05/01/1997, 06/01/2002, 01/01/2008

5160-8-24 [Rescinded] Eligible providers of certified registered nurse anesthetist (CRNA) services.

Cite as Ohio Admin. Code 5160-8-24

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 4723.41 to 4723.50
Prior Effective Dates: 03/30/1995, 06/01/2002, 01/01/2008

5160-8-25 [Rescinded] Coverage, limitations, and reimbursement of anesthesia services provided by certified registered nurse anesthesists (CRNAs).

Cite as Ohio Admin. Code 5160-8-25

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 03/30/1995, 05/01/2001, 09/01/2005

5160-8-26 [Rescinded] Anesthesiologist assistant (AA) services: eligible providers and coverage and limitations.

Cite as Ohio Admin. Code 5160-8-26

Effective: 1/1/2017
Five Year Review (FYR) Dates: 01/12/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02
Prior Effective Dates: 05/01/2001, 09/01/2005

5160-8-27 [Rescinded] Advanced practice nurses: : modifiers.

Cite as Ohio Admin. Code 5160-8-27

Effective: 1/1/2017
Five Year Review (FYR) Dates: 10/05/2016
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.70
Prior Effective Dates: 10/01/2003, 01/01/2010

5160-8-30 Skilled therapy: scope and definitions.

(A) Rules 5160-8-31 to 5160-8-34 of the Administrative Code set forth provisions governing payment for skilled therapies as non-institutional professional services. Provisions governing payment for skilled therapies as the following service types are set forth in the indicated part of the Administrative Code:

(1) Hospital services, Chapter 5160-2;

(2) Nursing facility services, Chapter 5160-3;

(3) Home health services, Chapter 5160-12;

(4) Clinic services rendered by the following providers:

(a) Fee-for-service ambulatory health care clinics, Chapter 5160-13;

(b) Rural health clinics, Chapter 5160-16;

(c) Federally qualified health centers, Chapter 5160-28; or

(d) Outpatient health facilities, Chapter 5160-29;

(5) Medicaid school program services, Chapter 5160-35; and

(6) Intermediate care facility services, Chapter 5123:2-7.

(B) The following definitions apply to rules 5160-8-31 to 5160-8-34 of the Administrative Code:

(1) "Audiologist" is a person who holds a valid license as an audiologist under Chapter 4753. of the Revised Code.

(2) "Audiology aide" is a person who holds a valid license as an audiology aide under Chapter 4753. of the Revised Code.

(3) "Developmental services" are skilled therapy services rendered, in accordance with developmental milestones established by the American academy of pediatrics, to enable individuals younger than seven years of age to attain a level of age-appropriate functionality that they have not yet achieved but are expected to achieve.

(4) "Developmental disability" has the same meaning as in section 5123.01 of the Revised Code.

(5) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(6) "Maintenance services" are skilled therapy services rendered to individuals for the purpose of maintaining but not improving functionality.

(7) "Mechanotherapist" is a person who holds a valid license as a mechanotherapist under Chapter 4731. of the Revised Code and works within the scope of practice defined by state law.

(8) "Non-institutional setting" is a location that is not a hospital or long-term care facility and that is appropriate to the delivery of skilled therapy services. Examples include but are not limited to practitioners' offices, clinics, licensed child day care centers, adult day care centers, and public facilities such as community centers.

(9) "Occupational therapist" is a person who holds a valid license as an occupational therapist under Chapter 4755. of the Revised Code and works within the scope of practice defined by state law.

(10) "Occupational therapy" has the same meaning as in section 4755.04 of the Revised Code.

(11) "Occupational therapy assistant" is a person who holds a valid license as an occupational therapy assistant under Chapter 4755. of the Revised Code.

(12) "Physical therapist" is a person who holds a valid license as a physical therapist under Chapter 4755. of the Revised Code and works within the scope of practice defined by state law.

(13) "Physical therapist assistant" is a person who holds a valid license as a physical therapist assistant under Chapter 4755. of the Revised Code.

(14) "Physical therapy" has the same meaning as in section 4755.40 of the Revised Code.

(15) "Rehabilitative services" are skilled therapy services rendered to individuals for the purpose of improving functionality.

(16) "Skilled therapist" is a collective term encompassing physical therapist, occupational therapist, speech-language pathologist, and audiologist.

(17) "Skilled therapy" is a collective term encompassing physical therapy, occupational therapy, speech-language pathology, and audiology.

(18) "Speech-language pathologist" is a person who holds a valid license as a speech-language pathologist under Chapter 4753. of the Revised Code.

(19) "Speech-language pathology aide" is a person who holds a valid license as a speech-language pathology aide under Chapter 4753. of the Revised Code.

(20) "Standardized test" is a diagnostic tool or procedure that has a standardized administration and scoring process, the results of which can be compared to an appropriate normative sample. Standardized tests must be norm-referenced, age-appropriate, and specific to areas of deficit.

(21) "Supplemental test" is a non-diagnostic screening or criterion-referenced tool that is used to provide further documentation of deficits and to corroborate the results of a standardized test. A supplemental test may not be used in place of a standardized test.

Replaces: Part of 5160-34- 01.1, part of 5160-34- 01.2

Cite as Ohio Admin. Code 5160-8-30

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 01/01/2008

5160-8-31 Skilled therapy: providers.

(A) Rendering providers.

(1) Independently practicing skilled therapists either must participate in the medicare program or, if they limit their practice to pediatric treatment and do not serve medicare beneficiaries, must meet all other requirements for medicare participation.

(2) The following eligible providers may render a physical therapy service:

(a) A physical therapist;

(b) A physical therapist assistant who is licensed to provide the particular service and who provides the service to only one person at a time under the supervision of an eligible provider;

(c) A physical therapy student who is completing an internship, if the following conditions are met:

(i) The service is provided under the supervision of the eligible provider responsible for the patient's therapy;

(ii) The eligible provider responsible for the patient's therapy has face-to-face contact with the patient during provision of the service;

(iii) The eligible provider responsible for the patient's therapy keeps on file official documentation of the internship, including the beginning and ending dates; and

(iv) The eligible provider responsible for the patient's therapy includes in the patient's medical record documentation that appropriate service was provided under supervision, that the eligible provider checked and updated the medical record at least once a week, and that all requirements for payment were met; or

(d) A mechanotherapist.

(3) The following eligible providers may render an occupational therapy service:

(a) An occupational therapist;

(b) An occupational therapy assistant who is licensed to provide the particular service and who provides the service to only one person at a time under the supervision of an eligible provider; or

(c) An occupational therapy student who is completing an internship, if the following conditions are met:

(i) The service is provided under the supervision of the eligible provider responsible for the patient's therapy;

(ii) The eligible provider responsible for the patient's therapy has face-to-face contact with the patient during provision of the service;

(iii) The eligible provider responsible for the patient's therapy keeps on file official documentation of the internship, including the beginning and ending dates; and

(iv) The eligible provider responsible for the patient's therapy includes in the patient's medical record documentation that appropriate service was provided under supervision, that the eligible provider checked and updated the medical record at least once a week, and that all requirements for payment were met.

(4) The following eligible providers may render a speech-language pathology service:

(a) A speech-language pathologist;

(b) A speech-language pathology aide who is licensed to provide the particular service and who provides the service to only one person at a time under the supervision of an eligible provider;

(c) A speech-language pathology student who is completing an internship, if the following conditions are met:

(i) The service is provided under the supervision of the eligible provider responsible for the patient's therapy;

(ii) The eligible provider responsible for the patient's therapy has face-to-face contact with the patient during provision of the service;

(iii) The eligible provider responsible for the patient's therapy keeps on file official documentation of the internship, including the beginning and ending dates; and

(iv) The eligible provider responsible for the patient's therapy includes in the patient's medical record documentation that appropriate service was provided under supervision, that the eligible provider checked and updated the medical record at least once a week, and that all requirements for payment were met; or

(d) A person holding a conditional license to practice speech-language pathology, if the eligible provider supervising the professional experience keeps on file a copy of the conditionally-licensed speech-language pathologist's plan of supervised professional experience, required by section 4753.071 of the Revised Code.

(5) The following eligible providers may render an audiology service:

(a) An audiologist;

(b) An audiology aide who is licensed to provide the particular service and who provides the service to only one person at a time under the supervision of an eligible provider;

(c) An audiology student who is completing an internship, if the following conditions are met:

(i) The student provides the service under the supervision of the eligible provider responsible for the patient's therapy;

(ii) The eligible provider responsible for the patient's therapy has face-to-face contact with the patient during provision of the service;

(iii) The eligible provider responsible for the patient's therapy keeps on file official documentation of the internship, including the beginning and ending dates; and

(iv) The eligible provider responsible for the patient's therapy includes in the patient's medical record documentation that appropriate service was provided under supervision, that the eligible provider checked and updated the medical record at least once a week, and that all requirements for payment were met; or

(d) An audiology student who is completing an externship, if the following conditions are met:

(i) The service is provided under the supervision of the eligible provider responsible for the patient's therapy; and

(ii) The eligible provider responsible for the patient's therapy keeps on file official documentation of the externship, including the beginning and ending dates.

(B) Billing ("pay-to") providers.

(1) The following eligible providers may receive medicaid payment for submitting a claim for a skilled therapy service on behalf of a rendering provider:

(a) A hospital, rules for which are set forth in Chapter 5160-2 of the Administrative Code;

(b) A provider of physician services, rules for whom are set forth in Chapter 5160-4 of the Administrative Code;

(c) A professional medical group;

(d) An ambulatory health care clinic, rules for which are set forth in Chapter 5160-13 of the Administrative Code;

(e) A rural health clinic, rules for which are set forth in Chapter 5160-16 of the Administrative Code;

(f) A federally qualified health center, rules for which are set forth in Chapter 5160-28 of the Administrative Code; or

(g) An outpatient health facility, rules for which are set forth in Chapter 5160-29 of the Administrative Code.

(2) The following eligible providers may receive medicaid payment either for rendering a skilled therapy service themselves or for submitting a claim for a skilled therapy service on behalf of a rendering provider:

(a) A skilled therapist; or

(b) A mechanotherapist.

Replaces: Part of 5160-8-01, part of 5160-8-02, part of 5160-8-03, part of 5160-34- 01.2

Cite as Ohio Admin. Code 5160-8-31

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 04/07/1977, 09/19/1977, 12/21/1977, 12/30/1977, 07/01/2002, 01/01/2008, 8/2/11

5160-8-32 Skilled therapy: coverage.

(A) Payment may be made for a skilled therapy service if the following conditions are met:

(1) The service is medically necessary, in accordance with rule 5160-1-01 of the Administrative Code.

(2) The service is rendered on the basis of a clinical evaluation and assessment and in accordance with a treatment plan. (Audiology must meet this condition in order to be considered skilled therapy for purposes of this chapter.) The performance of a clinical evaluation and assessment and the development of a treatment plan are discrete services; payment for them is made separately from payment for skilled therapy. The clinical evaluation and assessment and the treatment plan are described in rule 5160-8-33 of the Administrative Code; copies must be kept on file by the provider.

(3) The amount, frequency, and duration of treatment is reasonable. For rehabilitative services, the maximum treatment period without reevaluation is sixty days; for developmental services, the maximum treatment period without reevaluation is six months.

(B) The following limitations and additional requirements are placed on the provision of skilled therapy services:

(1) For dates of service January 1, 2014, and after, payment for skilled therapy services rendered without prior authorization in a non-institutional setting is subject to the following limits:

(a) For physical therapy services, a total of no more than thirty visits per benefit year;

(b) For occupational therapy services, a total of no more than thirty visits per benefit year; and

(c) For speech-language pathology and audiology services, a total of no more than thirty visits per benefit year.

(2) Payment for additional skilled therapy visits in a non-institutional setting can be requested through the prior authorization process, which is described in Chapter 5160-1 of the Administrative Code.

(3) For each type of skilled therapy, payment for evaluation services can be made not more than once per injury or condition.

(4) For each type of skilled therapy, payment for reevaluation of rehabilitative services cannot be made more often than once every sixty days.

(5) For each type of skilled therapy, payment for reevaluation of developmental services cannot be made more often than once every six months.

(6) No payment is made for the following services as skilled therapy:

(a) Services reported on a claim submitted by an entity that neither is nor acts on behalf of an eligible provider of skilled therapy services;

(b) Services not rendered by nor under the supervision of a physician or skilled therapist;

(c) Services that do not meet current accepted standards of practice;

(d) Services rendered in a non-approved location;

(e) Additional rehabilitative services for a patient who fails to demonstrate progress within a sixty-day treatment period;

(f) Additional developmental services for a patient who fails to demonstrate progress within a six-month treatment period;

(g) Consultations with family members or other non-medical personnel; and

(h) Services rendered in non-institutional settings and listed as non-covered in rule 5160-4-28 or in appendix DD to rule 5160-1-60 of the Administrative Code.

Replaces: Part of 5160-34- 01.2

Cite as Ohio Admin. Code 5160-8-32

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 01/01/2008

5160-8-33 Skilled therapy: documentation of services.

(A) A clinical evaluation and assessment of the need for skilled therapy services includes the following elements:

(1) A diagnosis of the type and severity of the disorder or a description of the deficit in physical or sensory functionality;

(2) A review of the individual's current physical, auditory, visual, motor, and cognitive status;

(3) A case history, including, when appropriate, family perspectives on the individual's development and capacity to participate in therapy;

(4) The outcomes of standardized tests and any non-standardized tests that use age-appropriate developmental criteria;

(5) Other test results and interpretation;

(6) An evaluation justifying the provision of skilled therapy services, which may be expressed as one of two prognoses of the patient's rehabilitative or developmental potential:

(a) The patient's functionality is expected to improve within sixty days after the evaluation because of the delivery of rehabilitative skilled therapy services or within six months after the evaluation because of the delivery of developmental skilled therapy services, and the patient is expected to attain full functionality or make significant progress toward expected developmental milestones within twelve months; or

(b) The patient is not expected to attain full functionality or make significant progress toward expected developmental milestones within twelve months, but a safe and effective maintenance program may be established; and

(7) Any recommendations for further appraisal, follow-up, or referral.

(B) A treatment or maintenance plan for skilled therapy services is based on the clinical evaluation and assessment. It should be coordinated, when appropriate, with services provided by non-medicaid providers or programs (e.g., child welfare, child care, or prevocational or vocational services), and it should provide a process for involving the patient or the patient's representative in the provision of services. A complete treatment or maintenance plan includes the following elements:

(1) The patient's relevant medical history;

(2) Specification of the amount, duration, and frequency of each skilled therapy service to be rendered; the methods to be used; and the areas of the body to be treated;

(3) A statement of specific functional goals to be achieved, including the level or degree of improvement expected within the appropriate time period;

(4) The date of each treatment;

(5) The signature of the practitioner responsible for the treatment plan;

(6) Documentation of participation by the patient or the patient's representative in the development of the plan;

(7) Specific timelines for reevaluating and updating the plan;

(8) A statement of the degree to which the patient has made progress; and

(9) A recommendation for one of several courses of action:

(a) The development of a new or revised treatment plan;

(b) The development of a maintenance plan; or

(c) The discontinuation of treatment.

Replaces: Part of 5160-34- 01.2

Cite as Ohio Admin. Code 5160-8-33

Effective: 01/01/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70
Prior Effective Dates: 01/01/2008

5160-8-34 Skilled therapy: payment.

(A) If more than one skilled therapy service of the same discipline (e.g., physical therapy) is rendered by the same non-institutional provider or provider group to a recipient on the same date, then the service with the highest payment amount specified in appendix DD to rule 5160-1-60 of the Administrative Code is considered the primary procedure. The maximum payment amount for a skilled therapy service is the lesser of the provider's submitted charge or a percentage of the amount specified in appendix DD to rule 5160-1-60 of the Administrative Code, determined in the following manner:

(1) For the first unit of a primary procedure, one hundred per cent.

(2) For each additional unit or procedure within the same therapy discipline, eighty per cent.

(B) Services reported on claims must correspond to the services listed in the treatment plan.

(C) Providers must report appropriate procedure codes and modifiers on claims.

(D) Unattended electrical stimulation and iontophoresis therapy are considered to be part of the associated therapy procedure or medical encounter; no separate payment is made.

(E) Skilled therapy performed during an inpatient hospital stay is treated as a hospital service.

(F) Payment for skilled therapy services rendered to a resident of a nursing facility (NF) is made to the NF through the facility per diem payment mechanism. A non-institutional provider that renders a skilled therapy service to a NF resident must seek payment from the NF.

Cite as Ohio Admin. Code 5160-8-34

Effective: 07/31/2014
R.C. 119.032 review dates: 01/01/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02 , 5164.06, 5164.70, 5165.47
Prior Effective Dates: 01/01/2008, 07/31/2009 (Emer), 10/29/2009, 01/01/2014

5160-8-41 Medical nutrition therapy services.

(A) Definitions.

(1) "Medical nutrition therapy" is the use of specific nutrition services to treat an illness, injury, or condition. Medical nutrition therapy services include nutrition assessment, intervention, and counseling.

(2) "Registered dietitian nutritionist" has the same meaning as "registered dietitian" in Chapter 4759. of the Revised Code.

(3) "Licensed dietitian" has the same meaning as "licensed dietitian" in Chapter 4759. of the Revised Code.

(B) Providers.

(1) Rendering providers. The following eligible providers may render a medical nutrition therapy service:

(a) A registered dietitian nutritionist; or

(b) A licensed dietitian.

(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for submitting a claim for a medical nutrition therapy service on behalf of a rendering provider:

(a) An independent registered dietitian nutritionist;

(b) An independent licensed dietitian;

(c) A professional medical group; or

(d) A fee-for-service ambulatory health care clinic.

(C) Coverage. Payment may be made for the following three medical nutrition therapy services listed in "Current Procedural Terminology," published by the American medical association (AMA), http://www.ama-assn.org:

(1) Initial assessment and intervention;

(2) Reassessment and intervention; and

(3) Group counseling.

(D) Claim payment. Payment for a covered medical nutrition therapy service is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

Cite as Ohio Admin. Code 5160-8-41

Effective: 5/8/2016
Five Year Review (FYR) Dates: 05/08/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02