Chapter 5160-8 Limited Practitioner Services

5160-8-01 [Rescinded] Eligible providers of limited practitioner services.

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5160-8-02 [Rescinded] Covered physical therapy services and limitations.

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5160-8-03 [Rescinded] Covered occupational therapy services and limitations.

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.

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

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 Advanced practice nurses.

(A) All the definitions set forth in rule 4723-08-01 of the Administrative Code apply to rules 5101:3-8-20 to 5101:3-8-23 of the Administrative Code unless otherwise indicated.

(B) Definitions.

(1) "Fee-for-service clinics" are clinics that are eligible and bill the department as ambulatory health clinics in accordance with Chapter 5101:3-13 of the Administrative Code.

(2) "Cost-based clinics" are clinics that are eligible and bill the department as a rural health clinic (RHC), a federally qualified health center (FQHC), or an outpatient health facility (OHF) in accordance with Chapters 5101:3-16, 5101:3-28 and 5101:3-29 of the Administrative Code, respectively.

(3) "Advanced practice nurse" for the purpose of rules 5101:3-8-21 to 5101:3-8-23 of the Administrative Code is a registered nurse who holds a certificate of authority issued by the board of nursing to practice as a certified nurse practitioner, clinical nurse specialist, or certified nurse midwife in accordance with section 4723.42 of the Revised Code and meets the criteria set forth in rule 5101:3-8-21 of the Administrative Code.

Effective: 01/01/2008
R.C. 119.032 review dates: 05/15/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50
Prior Effective Dates: 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

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

(A) A certified nurse practitioner approved under section 4723.42 of the Revised Code is eligible to become an Ohio medicaid provider as an individual nurse practitioner upon the execution of an Ohio medicaid provider agreement if both of the following are met:

(1) The certified nurse practitioner holds a valid certificate of authority issued by the Ohio board of nursing in accordance with section 4723.42 of the Revised Code.

(2) The certified nurse practitioner is certified by a national certifying organization approved by the Ohio board of nursing as at least one of the following:

(a) An adult nurse practitioner;

(b) A family nurse practitioner;

(c) A pediatric nurse practitioner;

(d) An obstetrical-gynecological/women's health care nurse practitioner;

(e) A neonatal nurse practitioner;

(f) A gerontological nurse practitioner;

(g) An acute care nurse practitioner;

(h) A psychiatric nurse practitioner; or

(i) A palliative care nurse practitioner.

(B) A clinical nurse specialist approved under section 4723.42 of the Revised Code is eligible to become an Ohio medicaid provider as an individual clinical nurse specialist upon execution of an Ohio medicaid provider agreement if both of the following are met:

(1) The clinical nurse specialist holds a valid certificate of authority issued by the Ohio board of nursing in accordance with section 4723.42 of the Revised Code.

(2) The clinical nurse specialist is certified by a national certifying organization approved by the Ohio board of nursing as at least one of the following:

(a) An oncology clinical nurse specialist;

(b) A clinical nurse specialist in adult health;

(c) A gerontological clinical nurse specialist;

(d) A psychiatric clinical nurse specialist;

(e) A palliative care nurse specialist;

(f) An acute care clinical nurse specialist; or

(g) A pediatric clinical nurse specialist.

(C) Clinical nurse specialists and certified nurse practitioners not meeting the criteria in paragraphs (A)(1) and (A)(2) or paragraphs (B)(1) and (B)(2) of this rule, as applicable, are not eligible for enrollment as a provider in the medicaid program.

(D) A certified nurse midwife approved under section 4723.42 of the Revised Code is eligible to become an Ohio medicaid provider as an individual nurse midwife upon execution of an Ohio medicaid provider agreement if all of the following are met:

(1) The certified nurse midwife holds a valid certificate of authority issued by the Ohio board of nursing in accordance with section 4723.42 of the Revised Code.

(2) The certified nurse midwife has completed an accredited course of study.

(3) The certified nurse midwife is certified by the American college of nurse-midwives, the American midwifery certification board, or the American college of nurse midwives certification council.

(E) An advanced practice nurse group is eligible to enroll in the medicaid program if it meets the criteria as a professional medical group as defined in paragraph (C) of rule 5101:3-1-17 of the Administrative Code.

(F) Advanced practice nurses enrolled in the medicaid program may be members of any physician group practice enrolled in the Ohio medicaid program.

(G) Out-of-state advanced practice nurses providing services to Ohio medicaid recipients must be licensed, certified, or authorized as required by the state in which the recipient is located at the time the service is provided. In addition, out-of-state advanced practice nurses must meet the provisions of rule 5101:3-1-11 of the Administrative Code addressing out-of-state coverage.

(H) Any advanced practice nurse practicing in Ohio who applies to become a medicaid provider must be authorized by the Ohio board of nursing to practice as an advanced practice nurse in accordance with sections 4723.41 and 4723.42 of the Revised 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
Prior Effective Dates: 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02, 1/1/08

5160-8-22 Advanced practice nurses practice arrangements and reimbursement.

(A) Advanced practice nurses enrolled in the Ohio medicaid program may practice in a variety of practice or employment arrangements as specified in the nurse's standard care arrangement in accordance with section 4723.431 of the Revised Code. Whether an advanced practice nurse or a group of advanced practice nurses is entitled to direct reimbursement under the Ohio medicaid program is dependent entirely on the practice or employment arrangement of the advanced practice nurse or group.

(B) Practice arrangements.

(1) Independent practice.

An "advanced practice nurse" is considered to be in an independent practice if the medical services rendered to a patient are the responsibility of an advanced practice nurse who is in solo practice or a member of an advanced practice nurse group practice and the practice is free of the fiscal, administrative, and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or any other medicaid provider. "Free of professional control" does not mean that the advanced practice nurse practices in the absence of a standard care arrangement. Each advanced practice nurse, including those in independent practice as defined in this rule, must maintain a standard care arrangement as required by section 4723.431 of the Revised Code.

(2) Provider-based practice.

An "advanced practice nurse" is considered to be in a provider-based practice if the advanced practice nurse is under the fiscal, administrative and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or any other medicaid provider through an employment, a contractual, or any other legally binding arrangement. Advanced practice nursing services provided in provider-based practices are considered incidental to the employing or contractual provider (i.e., as physician services if provided in a physician-based practice, as clinic services if provided in a clinic-based practice, as hospital services if provided in a hospital-based practice, etc.).

(C) Reimbursement.

(1) Services provided by advanced practice nurses are subject to the site differential payments set forth in rule 5101:3-4-02.2 of the Administrative code and the office incentive payments set forth in rule 5101:3-4-09 of the Administrative Code.

(a) The total reimbursement for services and procedures subject to the site differential payment is either the provider's billed charge or the reimbursement rate established in paragraphs (C)(3) and (C)(4) of this rule multiplied by the site differential percentage rate, whichever is less.

(b) The total reimbursement for services and procedures subject to the office incentive payment is either the provider's billed charges or the reimbursement rate established in paragraphs (C)(3) and (C)(4) of this rule plus the incentive payment rate, whichever is less.

(2) Separate reimbursement is not available for any service included in the global payment of another service (e.g., evaluation and management services provided for post-operative care), whether the global payment was made directly to the advanced practice nurse or to another medicaid provider.

(3) Only advanced practice nurses who practice in an independent practice arrangement are eligible to bill and receive direct reimbursement under the Ohio medicaid program. For independent practices, reimbursement is the lesser of the provider's billed charge or one of the following:

(a) Eighty-five per cent of the medicaid maximum when services are provided in a hospital setting; or

(b) One hundred per cent of the medicaid maximum when services are provided in a nonhospital setting.

(4) Services provided by advanced practice nurses in provider-based practices are reimbursable only to the employing or contracting provider.

(a) For individual physician-based practices, group physician-based practices, fee-for-service clinic-based practices, or hospital-based practices;, reimbursement for advanced practice nursing services is the lesser of the provider's billed charge or one of the following:

(i) Eighty-five per cent of the medicaid maximum when services are provided by an advanced practice nurse in the following places of service: inpatient hospital, outpatient hospital, or hospital emergency department; or

(ii) One hundred per cent of the medicaid maximum when services are provided by an advanced practice nurse in any nonhospital place or service.

(b) For RHC-based, FQHC-based and OHF-based practices, reimbursement for advanced practice nursing services is the medicaid maximum set forth in Chapters 5101:3-16, 5101:3-28, and 5101:3-29 of the Administrative Code, respectively.

(c) For all other nonhospital, provider-based practices, reimbursement for advanced practice nursing services is bundled into the payment for that provider type and is the maximum allowed under the medicaid program for the services rendered by that provider type (e.g., services provided by a nurse practitioner employed by a home health agency would be bundled into the payment for a home health service).

(d) When services incident to advanced practice nurse services are provided by an individual who is not an advanced practice nurse in an office or clinic setting, the services rendered must be within the scope of licensure (if licensure is required) of the individual who is not an advanced practice nurse or a service for which the individual is legally authorized to provide under Ohio law and documented in the patient's medical records.

(i) The services rendered by the individual who is not an advanced practice nurse must be rendered under the direct supervision of the advanced practice nurse. The records must be reviewed and countersigned by the supervising advanced practice nurse.

(ii) "Direct supervision" in the advanced practice nurse's office or clinic setting means-that the advanced practice nurse must be present in the office suite throughout the time the individual who is not an advanced practice nurse is providing the service and immediately available to provide assistance and direction throughout the time the individual who is not an advanced practice nurse is performing services. Direct supervision does not mean the advanced practice nurse must be in the same room while the individual who is not an advanced practice nurse is providing services. The availability of the advanced practice nurse by telephone or the presence of the advanced practice nurse somewhere in the institution does not constitute availability.

(iii) All of the provisions relating to direct supervision described in rule 5101:3-4-02 of the Administrative Code must be met.

(5) Hospital-based advanced practice nurses.

(a) For hospital-based practices, separate reimbursement is available to hospitals for professional services provided by advanced practice nurses only if the requirements set forth in paragraph (C)(5)(c) of this rule are met. Reimbursement for professional services provided by hospital-based advanced practice nurses is in accordance with paragraph (C)(4)(a) of this rule. In addition, certain services are subject to the site differential payment in accordance with paragraph (C)(1) of this rule.

(b) Services provided by advanced practice nurses that include teaching, research, administration, supervision of professional and/or technical personnel, supervision of nursing and advanced practice nursing students, service on hospital committees, and other hospital-based activities that are of benefit to patients, generally do not meet all of the requirements set forth in paragraph (C)(5)(c) of this rule.

(i) Such services are reimbursable only as hospital services and are bundled into the hospital's inpatient or outpatient facility payment in accordance with Chapter 5101:3-2 of the Administrative Code; and

(ii) The portion of the expenses associated with the provision of the type of services identified in paragraph (C)(5)(b) of this rule by an advanced practice nurse, may be included on the hospital cost report.

(c) Reimbursement for services rendered directly to, and for the benefit of, individual patients by advanced practice nurses who are employed by or under contract with a hospital is separately reimbursable to the hospital on a fee-for-service basis as advanced practice nursing services (i.e., in addition to the inpatient or outpatient hospital facility payment) if the following requirements are met:

(i) The services are personally furnished for an individual patient by an advanced practice nurse who is currently enrolled as an Ohio medicaid provider.

(ii) The services contribute directly to the diagnosis or treatment of an individual patient.

(iii) The services ordinarily require performance by a physician or an advanced practice nurse.

(iv) The services are not the type of services routinely performed by registered nurses or other hospital-employed nonphysicians.

(v) For services identified in paragraphs (C)(5)(c)(i) to (C)(5)(c)(iv) of this rule, documentation must exist that demonstrates the advanced practice nurse's involvement in the service rendered. A countersignature alone in the records is not considered sufficient documentation of advanced practice nursing services.

(vi) The portion of the expenses associated with the provision of the type of services identified in paragraphs (C)(5)(c)(i) to (C)(5)(c)(iv) of this rule by advanced practice nurses are excluded from the hospital cost report.

(6) In an institutional setting, advanced practice nurses will only be reimbursed by the medicaid program for the services that have been personally rendered by the advanced practice nurse.

Effective: 01/01/2008
R.C. 119.032 review dates: 05/15/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50
Prior Effective Dates: 9/24/83, 4/1/88, 5/15/89, 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

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

(A) The coverage of services provided by advanced practice nurses shall be limited only to the extent that the condition of the patient and/or the limited scope of practice of an advanced practice nurse as it is recognized under Ohio law warrants the intervention and/or care of a physician in a capacity other than one of advisory, collaborating, or for the purposes of prescribing pharmaceuticals or medical devices when the advanced practice nurse lacks prescriptive authority.

(B) Chapter 5101:3-14 of the Administrative Code and all the rules set forth in Chapter 5101:3-4 of the Administrative Code that pertain to services a physician is legally authorized to perform under Ohio law shall apply to advanced practice nurses except, the term "physician" as it is defined in rule 5101:3-4-01 of the Administrative Code shall be replaced with the term"advanced practice nurse" as it is defined in rule 5101:3-8-21 of the Administrative Code.

(C) In addition to being subject to the applicable rules set forth in Chapter 5101:3-4 of the Administrative Code, advanced practice nurses are subject to the following coverage and limitations:

(1) For services provided in a teaching setting for advanced practice nurses, paragraphs (A) and (E)(2) in rule 5101:3-4-05 of the Administrative Code shall apply except the term"physician" in this rule shall be replaced by the term "advanced practice nurse" and the term "resident, intern, or fellow" shall be replaced by the term "individual in training for an advanced practice nursing certification.".

(2) Under no circumstances will an advanced practice nurse be eligible to bill or be reimbursed for the following evaluation and management CPT code: 99223,

(3) Consultations performed by an advanced practice nurse are covered.

(4) Except when precluded by Ohio law, inpatient hospital evaluation and management services are covered only if the advanced practice nurse is acting in the capacity of the patient's "primary treating provider" for the day and no physician is acting concurrently as the primary treating provider, and billing for evaluation and management services. For purposes of this rule, "primary treating provider" is a physician or advanced practice nurse who is responsible for managing the patient's inpatient hospital care for that day. "Primary treating provider" does not include a sub-specialist provider who may be treating the patient concurrently for specialty care, (e.g. a nephrologist).

(5) Antepartum services may be provided by advanced practice nurses who are certified in an advanced practice nurse specialty that is qualified to perform antepartum services.

(6) "Covered nurse midwifery services" are defined as those services that constitute the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically. Only advanced practice nurses who are certified nurse midwives may perform and bill for deliveries. In addition, the following services are noncovered when performed by nurse midwives, except in unavoidable, emergency situations:

(a) Management of an acute obstetric emergency, including any obstetric operation;

(b) Version or delivery of breech or face presentation; and

(c) Use of forceps;

(7) Therapeutic injections, prescribed drugs, diagnostic and therapeutic services, laboratory services, and radiology services are covered as an advanced practice nursing service only if the service was ordered and/or prescribed by a physician, an advanced practice nurse, or any other provider who has the authority to order and/or prescribe the services under, and in accordance with, Ohio law.

(8) With the exception of those laboratory procedures listed as physician-performed microscopy procedures (PPMP), laboratory services that require performance by a pathologist or a physician who is regarded as a specialist in pathological or hematological medicine (e.g., physician professional services associated with the gross or microscopic examination of surgical pathology tissues), are not covered if they are performed by an advanced practice nurse.

(9) Professional radiology or diagnostic and therapeutic services are covered by an advanced practice nurse if the advanced practice nurse is within his or her scope of practice.

(10) If a physician and an advanced practice nurse provide the same covered service, (e.g. any evaluation and management service), or participate in the provision of a global/all-inclusive service that involves multiple visits on the same or different days, only one provider is entitled to reimbursement for the service.

(a) Unless otherwise agreed upon by the two providers, the physician or the employing provider of the physician shall be the provider entitled to reimbursement if the condition of the patient and/or the limited scope of practice of an advanced practice nurse warrants the intervention and/or care of a physician in a capacity other than one of advisory, collaborating, or for the purpose of prescribing pharmaceuticals, medical devices, or other diagnostic and therapeutic services when the advanced practice nurse lacks the prescriptive authority required.

(b) Separate reimbursement is not available for the physician's supervision of or collaboration with an advanced practice nurse. Any cost associated with the supervisory role of a physician is the responsibility of the advanced practice nurse or advanced practice nurse group if the advanced practice nurse is in an independent practice arrangement, or the responsibility of the employing provider if the advanced practice nurse is in a provider-based practice arrangement.

(D) The following services are noncovered:

(1) Emergency room visit codes 99284 and 99285 are not covered if billed by an advanced practice nurse who is in an independent practice as defined in rule 5101:3-8-22 of the Administrative Code.

(2) All services exceeding the policies and limitations defined in Chapters 5101:3-1, 5101:3-4 and 5101:3-14 of the Administrative Code and rules 5101:3-8-20 and 5101:3-8-25 of the Administrative Code;

(3) All services exceeding the scope of practice of an advanced practice nurse under, and in accordance with, Ohio law;

(4) Any service exceeding the scope of practice of an advanced practice nurse as defined in the standard care arrangement;

(5) Services determined by the department as not medically necessary as defined in rule 5101:3-1-01 of the Administrative Code or that are duplicative in respect to a service provided concurrently by a physician or other valid medicaid provider;

(6) Assistant-at-surgery services;

(7) Services of residents, interns, and fellows provided in a teaching setting supervised by an advanced practice nurse; and

(8) All services itemized as noncovered in rule 5101:3-4-28 of the Administrative Code.

Effective: 01/01/2008
R.C. 119.032 review dates: 05/15/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50
Prior Effective Dates: 9/24/83, 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02

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

(A) Any certified registered nurse anesthetist (CRNA) who holds a current, valid certificate of authority issued under, and in accordance with, Ohio law entitling the holder to practice as a nurse anesthetist is eligible to participate in Ohio's medicaid program and provide covered CRNA services upon the execution of the Ohio medicaid provider agreement.

(B) A CRNA group practice must meet the criteria as a professional group practice as defined in paragraph (C) of rule 5101:3-1-17 of the Administrative Code and is organized for the purpose of providing CRNA services.

(C) A CRNA who is licensed or holds a current certificate, or similar document under another state's law entitling the holder to practice as a nurse anesthetist, is eligible to participate in Ohio's medicaid program and provide covered CRNA services as long as the following are met:

(1) The services are rendered to eligible Ohio recipients in the state in which the CRNA is authorized to practice;

(2) The provider of CRNA services has a currently valid provider agreement with the department; and

(3) The provisions in rule 5101:3-1-11 of the Administrative Code addressing out-of-state coverage are met.

(D) A CRNA that meets the criteria set forth in paragraphs (A) to (C)(2) of this rule is entitled to receive an Ohio medicaid legacy number. CRNA services may be billed if the following conditions are met:

(1) The provisions of paragraph (B) or (C) of rule 5101:3-8-25 of the Administrative Code are met; and

(2) The provisions outlined in rule 5101:3-1-17 of the Administrative Code are met.

Effective: 01/01/2008
R.C. 119.032 review dates: 05/15/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 4723.41 to 4723.50
Prior Effective Dates: 3/30/95, 6/1/02

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

(A) The department will reimburse a CRNA for general, regional or supplementation of local anesthesia services (monitored anesthesia care as described in paragraph (I) of rules 5101:3-4-21 of the Administrative Code) provided during a surgical or diagnostic procedure. Anesthesia services include the basic preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluid and/or blood products incident to the anesthesia or surgery, and the usual monitoring procedures. Anesthesia services include ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry as usual monitoring procedures. Unusual monitoring procedures (e.g., intra-arterial, central venous and swan-ganz) are not included and may be separately billed and reimbursed as long as the performance of these services are not limited by Ohio law.

(B) A CRNA is considered to be self-employed if the CRNA is in a solo practice and the practice is free of the fiscal, administrative, and professional control of a CRNA group practice, an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider type.

(C) An independent CRNA group practice is a practice composed solely of two or more CRNAS enrolled under the medicaid program and the practice is free of the fiscal, administrative, and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider.

(D) Reimbursement for anesthesia services provided by a CRNA may be made directly to a CRNA provider type only if the services were provided by a self-employed CRNA or by a CRNA employed by an independent CRNA group practice.

(E) A CRNA's provider number may be listed on a medicaid invoice under the following circumstances only:

(1) When a claim is being submitted for anesthesia services provided by a CRNA who either is self-employed or a member of an independent CRNA group practice;

(2) When a crossover ("F-type") claim is being submitted, in accordance with paragraph (G)(2) of this rule, for medicare co-insurance and deductible payments;

(3) When a claim is being submitted, in accordance with paragraph (H)(2) of this rule, for anesthesia services that were provided by a non-medically directed physician-employed CRNA; or

(4) When a claim is being submitted in accordance with paragraph (H)(1) of this rule, for anesthesia services that were provided by a medically-directed or medically-supervised physician-employed CRNA.

(F) A CRNA is considered to be:

(1) "Medically directed" if anesthesia services are provided with a physician who meets all of the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code;

(2) "Nonmedically directed" if anesthesia services are provided without a physician who meets all of the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code; and

(3) "Medically supervised" if anesthesia services are provided with a physician who meets all of the conditions set forth in paragraph (C) (4) of rule 5101:3-4-21 of the Administrative Code.

(G) Separate reimbursement will be made for the medicare coinsurance and deductible amounts due for medicare covered CRNA services provided to a patient who is dually eligible for medicare and medicaid, even if direct reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g, hospital-employed CRNA services, physician-employed CRNA services, etc.).

(1) The co-insurance and deductible payments should normally be made through the automatic crossover mechanism.

(2) If the claims did not get paid through the automatic crossover mechanism, the provider must submit a medicaid crossover "F-type 6780" claim, in accordance with the crossover billing instructions except that the CRNA's provider number must be submitted as the rendering provider and the employing provider number must be submitted as the pay to provider.

(H) The following CRNA reimbursement policies apply when services are provided to medicaid patients who are not also covered under medicare.

(1) Reimbursement of anesthesia services provided by a medically directed or medically supervised physician-employed CRNA.

When anesthesia services are provided by a CRNA who is under the employment of an individual or group physician practice and medical direction was provided by a physician in the practice, reimbursement for the services of the CRNA and the directing physician is paid to the employing physician or physician group practice as described in paragraph (H)(3)(b)(ii) of rule 5101:3-4-21 of the Administrative Code. For reimbursement, the physician who provided the medical direction would be listed as the rendering provider and the appropriate modifier indicating medical direction listed in paragraph (D)(1) of rule 5101:3-4-21 of the Administrative Code must be billed.

(2) Reimbursement of anesthesia services provided by a non-medically directed and non-medically supervised physician-employed CRNA.

(a) When anesthesia services are provided by a CRNA who is under the employment of an individual or group physician practice and medical direction was not provided by a physician in the practice, reimbursement for the services of the CRNA is reimbursable only to the employing physician or physician group practice.

(b) For reimbursement:

(i) The provider number of the employing individual physician practice or the employing physician group practice must be listed in the group practice space on the invoice;

(ii) The provider number of the CRNA must be listed in the rendering provider space on the invoice; and

(iii) The appropriate anesthesia code must be modified with the QZ modifier.

(3) Reimbursement of anesthesia services provided by hospital-employed CRNAs.

Direct reimbursement is not available for anesthesia services provided by a hospital employed CRNA. The reimbursement for the services provided by the CRNA is bundled into the facility payment made to the hospital. When a physician provides medical direction to a CRNA who is employed by the hospital, only the physician who provided the medical direction to the CRNA is entitled to reimbursement on a fee-for-service basis.

(4) Reimbursement of anesthesia services provided by self-employed CRNAs or CRNAs who are members of an independent CRNA group practice.

(a) Direct reimbursement for anesthesia services provided by a self-employed CRNA or a CRNA who is a member of an independent CRNA group practice is available whether or not the CRNA is medically directed by a physician.

(b) When a physician provides medical direction or medical supervision to a CRNA who is self-employed or a member of an independent CRNA group practice, reimbursement for the medical direction of the CRNA is also available to the physician and must be billed in accordance with rule 5101:3-4-21 of the Administrative Code.

(c) Reimbursement is not available for supervision services provided by a physician when the physician does not meet the conditions set forth in paragraph (C) of rule 5101:3-4-21 of the Administrative Code.

(d) The CRNA or CRNA group practice must bill the code for the appropriate anesthesia code modified by either the QX or QZ modifier and report the total anesthesia time in minutes.

(i) If the CRNA was medically directed or medically supervised, the procedure code must be modified with the QX modifier.

(ii) If the CRNA was not medically directed, the procedure code must be modified with the QZ modifier.

(e) The policies contained in paragraphs (B), (D)(3), (E), (F) and (G) of rule 5101:3-4-21 of the Administrative Code also apply when anesthesia services are provided and billed by CRNAs.

(I) When a CRNA provides supervision and personal direction to a student nurse anesthetist involved in the provision of anesthesia services, reimbursement for the services of the CRNA is available in accordance with paragraph (G) of this rule. Reimbursement for the services of the student nurse anesthetist is bundled into the reimbursement made to the facility or hospital.

Effective: 09/01/2005
R.C. 119.032 review dates: 06/06/2005 and 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 3/30/95, 5/1/01

5160-8-26 [Effective until 1/1/2017] Anesthesiologist assistant (AA) services: eligible providers and coverage and limitations.

(A) Definitions.

(1) "Anesthesiologist assistant (AA) group practice" is two or more AAs organized for the purpose of providing AA services.

(2) "Anesthesiologist assistant" (AA) is an individual recognized under Chapter 4760. of the Revised Code as an AA.

(3) "Anesthesiologist-employed AA" is an AA employed by an anesthesiologist.

(4) "Hospital-employed AA" is an AA employed by a hospital.

(5) "Independent AA group practice" is two or more AAs organized for the purpose of providing AA services and free of the fiscal and administrative control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider.

(6) "Self-employed AA" is an AA in a solo practice that is free of the fiscal and administrative control of an independent AA group practice, an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, or any other medicaid provider type.

(7) "Medical direction" means, in accordance with paragraph (C)(3)(a) of rule 5101:3-4-21 of the Administrative Code, that a physician who meets the requirement set forth in paragraph (C)(1) of rule 5101:2-4-21 of the Administrative Code utilizes the assistance of an AA in the performance of anesthesia services.

(B) Eligible providers.

(1) Any AA who holds a current valid certificate of registration issued by the state medical board may request an Ohio medicaid provider number.

(2) Any AA group practice whose members hold current valid certificates of registration issued by the state medical board may request an Ohio medicaid provider number.

(3) Only self-employed AAs and members of independent AA group practices may submit medicaid claims for direct reimbursement under their individual or AA group practice provider numbers.

(4) The department will directly reimburse an AA for anesthesia services only if the services were provided by the self-employed AA or member of the independent AA group practice.

(C) Coverage and limitations.

(1) The department will reimburse for general, regional, or supplementation of local anesthesia services of an AA, as described in rule 5101:3-4-21 of the Administrative Code, only when an AA is under the direct supervision and in the immediate presence of an anesthesiologist, in accordance with Chapter 4760. of the Revised Code.

(2) The department will not reimburse any medicaid provider for services not provided in accordance with state and local laws.

(3) Medicaid claims for services provided by an AA must include the appropriate anesthesia code modified by the QX modifier, indicating that the anesthesia services were provided under appropriate medical direction, and report the total anesthesia time in minutes.

(4) Self-employed AAs and independent AA group practices.

(a) Self-employed AAs and independent AA group practices may submit medicaid claims for direct reimbursement under their individual or group practice medicaid provider numbers only for services they provided as a self-employed AA or member of an independent AA group practice.

(b) The policies contained in paragraphs (B), (D)(3), (E), (F), and (G) of rule 5101:3-4-21 of the Administrative Code apply to self-employed AAs and members of independent AA group practices who provide anesthesia services and submit medicaid claims for direct reimbursement.

(c) Reimbursement for the medical direction of the AA is available to the anesthesiologist providing the medical direction and must be billed in accordance with rule 5101:3-4-21 of the Administrative Code.

(5) Anesthesiologist-employed AAs.

(a) The department will reimburse the employing anesthesiologist or anesthesia group practice in accordance with rule 5101:3-4-21 of the Administrative Code for services of an AA and the directing anesthesiologist when anesthesia services are provided by an AA who is under the employment of an individual or group physician practice and medical direction was provided by an anesthesiologist in the practice.

(6) Hospital-employed AAs.

(a) The department will not directly reimburse for anesthesia services provided by a hospital-employed AA. The department bundles reimbursement for the services provided by the AA into the facility payment made to the hospital.

(b) The department will reimburse the anesthesiologist who provided medical direction to the AA when the anesthesiologist provides medical direction to a hospital-employed AA.

(D) Separate reimbursement will be made for the medicare coinsurance and deductible amounts due for medicare covered AA services provided to a patient who is dually eligible for medicare and medicaid, even if direct reimbursement would not be allowable if the anesthesia services are provided to a patient covered only under the medicaid program (e.g, hospital-employed AA services, etc.).

(1) The coinsurance and deductible payments should be made through the automatic medicare crossover process in accordance with rule 5101:3-1-05 of the Administrative Code.

(2) If claims are not paid through the automatic medicare crossover process, the provider must submit a medicaid crossover claim, in accordance with the crossover billing instructions.

Replaces: 5101:3-8-26

Effective: 09/01/2005
R.C. 119.032 review dates: 09/01/2010
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 05/01/2001

5160-8-26 [Rescinded effective 1/1/2017] Anesthesiologist assistant (AA) services: eligible providers and coverage and limitations.

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 Advanced practice nurses: : modifiers.

Effective for services provided on and or after October 1, 2003, when billing for any service provided by an advanced practice nurse (APN), whether the APN is in independent practice or a provider-based practice as described in rule 5101:3-8-22 of the Administrative Code, all services must be billed with a the appropriate modifier to denote the type of APN that provided the service:

(A) Bill the modifier "SA" e.g. 99201SA, if the APN is a nurse practitioner;

(B) Bill the modifier "SB" e.g. 99201SB, if the APN is a nurse mid-wife; or

(C) Bill the modifier "UC" e.g. 99201UC if the APN is a clinical nurse specialist.

Effective: 01/01/2010
R.C. 119.032 review dates: 05/13/2009 and 01/01/2015
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 10/1/2003

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

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

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

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

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.

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.

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