Chapter 5160-4 | Medical and Surgical Services

Rule 5160-4-01 | Physician services.

• Effective: March 1, 2022
• Promulgated Under: 119.03

(A) Separate payment may be made for covered professional services rendered by a physician employed by or under contract with a facility such as a hospital or long-term care facility (i.e., a "facility-based" physician) only if the following conditions are met:

(1) The services contribute directly to the diagnosis or treatment of an individual patient;

(2) Any applicable requirements set forth in agency 5160 of the Administrative Code are satisfied; and

(3) The expenses associated with the provision of the professional services are excluded from the cost report of the facility.

(B) In addition to professional services, a facility-based physician often performs other services that are of benefit to patients in general (e.g., teaching; research; administration; supervision of professional or technical personnel, residents, interns, or fellows; or service on provider committees). Payment for such services may be made only to the employing or contracting provider.

(C) For the sole purpose of demonstrating eligibility for incentive payments made in accordance with Section 4201 of the American Recovery and Reinvestment Act of 2009 (ARRA, Pub. L. No. 111-5), codified at 42 U.S.C. 1396b (as revised December 27, 2020), and with the regulations published at 42 C.F.R. Part 495 (October 1, 2021), an optometrist operating within the appropriate scope of practice defined in section 4725.01 of the Revised Code is considered to be a physician.

Last updated March 1, 2022 at 8:32 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 3/1/2027
Prior Effective Dates: 10/1/1983 (Emer.), 12/29/1983, 3/26/2001, 12/2/2011 (Emer.)

Rule 5160-4-02 | Supervision of professional services.

• Effective: September 1, 2021
• Promulgated Under: 119.03

(A) Definitions that apply to this rule.

(1) "Independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services without supervision.

(2) "Non-independent practitioner" is a practitioner who, under Ohio law, may provide healthcare services only with supervision.

(3) "Supervision" is a collective term encompassing two types of professional oversight:

(a) A practitioner providing direct supervision is present in the practice setting, although not necessarily in the same room, and is immediately available to provide assistance and direction throughout the provision of services. Neither availability by telephone nor presence nearby outside the practice setting constitutes direct supervision.

(b) A practitioner providing general supervision is available, although not necessarily present in the practice setting, to provide assistance and direction throughout the provision of services. A practitioner who is not physically present has the capability to provide immediate consultation by communications device and can travel to the practice setting quickly in case of emergency.

(B) Coverage. Payment may be made to the following practitioners only if the specified services are provided and the indicated conditions are met.

(1) An independent practitioner, for a service provided by a non-independent practitioner under general supervision:

(a) The non-independent practitioner functions in one of the following capacities:

(i) An employee of the supervising independent practitioner or of the practice in which the supervising independent practitioner participates; or

(ii) An independent contractor engaged by the supervising independent practitioner through a written agreement;

(b) The professional control exercised by the supervising independent practitioner or the practice of the supervising independent practitioner is the same for both employees and independent contractors; and

(c) The service was provided in connection with a covered healthcare service that represents an expense to the practice of the supervising independent practitioner.

(2) An independent practitioner, for a service provided by a non-independent practitioner under direct supervision:

(a) All of the conditions specified in paragraph (B)(1) of this rule are met; and

(b) Either of the following conditions is met:

(i) The supervising independent practitioner personally rendered a professional service to initiate the course of treatment, to which the service performed by the non-independent practitioner is incidental; or

(ii) The supervising independent practitioner rendered subsequent services at a frequency indicating continued participation in the management of the course of treatment.

(C) Constraints and limitations.

(1) Services provided by an independent practitioner who is employed by or under contract with another independent practitioner are not subject to the supervision provisions set forth in this rule.

(2) Nothing in this rule constitutes an exemption either from the fundamental principle that services rendered are within a practitioner's scope of licensure or practice or from any supervision standard established in law, regulation, statute, or rule.

(3) No separate payment is made for a professional service provided in a nursing facility (NF), skilled nursing facility (SNF), intermediate care facility for individuals with intellectual disabilities (ICFIID), inpatient hospital, outpatient hospital, or hospital emergency department by a non-independent practitioner employed by the facility or hospital, even if an independent practitioner ordered the service.

Last updated September 1, 2021 at 8:28 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 9/1/2026
Prior Effective Dates: 4/7/1977, 5/19/1986, 7/1/1987, 4/1/1992 (Emer.), 7/1/1994, 2/16/2009

Rule 5160-4-02.3 | Exception for certain services provided by residents.

• Effective: September 1, 2021
• Promulgated Under: 119.03

(A) The provisions set forth in paragraph (B) of rule 5160-4-02 of the Administrative Code do not apply when both of the following criteria are met:

(1) A healthcare service is provided by a resident participating in an approved graduate medical education (GME) program; and

(2) The conditions specified in 42 C.F.R. 415.174 (October 1, 2020) are satisfied.

(B) No separate payment will be made for services rendered by an unsupervised resident at a location not specified in 42 C.F.R. 415.174 (October 1, 2020).

Last updated September 1, 2021 at 8:28 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 9/1/2026
Prior Effective Dates: 4/7/1977, 12/21/1977, 12/30/1977, 9/1/1989

Rule 5160-4-03 | Services provided by a physician assistant.

• Effective: January 1, 2022
• Promulgated Under: 119.03

(A) Definitions.

(1) "Physician assistant" has the same meaning as in Chapter 4730. of the Revised Code.

(2) "Physician" has the same meaning as in section 4730.01 of the Revised Code.

(3) "Health care facility" has the same meaning as in section 4730.01 of the Revised Code.

(4) "Service" has the same meaning as in section 4730.01 of the Revised Code.

(B) Coverage. For a covered service performed by a physician assistant who is currently enrolled as an Ohio medicaid provider, payment may be made only if the physician assistant practices under either of the following arrangements:

(1) The physician assistant provides services under the supervision, control, and direction of a physician with whom the physician assistant has entered into a supervision agreement under section 4730.19 of the Revised Code; or

(2) The physician assistant practices in a health care facility and provides services the facility has authorized the physician assistant to perform.

(C) Payment.

(1) For assistant-at-surgery services performed by a physician assistant, payment is twenty-five per cent of the medicaid maximum for the covered primary surgical procedure.

(2) For a covered immunization, injection of medication, or provider-administered pharmaceutical, payment is made in accordance with rule 5160-4-12 of the Administrative Code.

(3) For all other covered services performed by a physician assistant, payment is the lesser of the billing provider's submitted charge or eighty-five per cent of the medicaid maximum.

(4) Payment for services provided by a hospital-employed physician assistant will be made to the hospital.

Last updated January 3, 2022 at 9:48 AM

Supplemental Information

Authorized By: 5164.02, 5164.301
Amplifies: 5164.02, 5164.301
Five Year Review Date: 1/1/2027
Prior Effective Dates: 9/1/1989, 4/1/1992 (Emer.), 11/1/2001, 1/1/2017

Rule 5160-4-04 | Advanced practice registered nurse (APRN) services.

• Effective: January 1, 2022
• Promulgated Under: 119.03

(A) Definition. "Advanced practice registered nurse (APRN)" has the same meaning as in Chapter 4723-08 of the Administrative Code. The term encompasses a certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), certified nurse-midwife (CNM), and certified nurse practitioner (CNP).

(B) Coverage.

(1) Unless a specific exception is noted, all other rules in agency 5160 of the Administrative Code that pertain to services rendered by a physician apply also to services rendered by an APRN.

(2) For a covered service rendered by an APRN, payment may be made only if the following conditions are met:

(a) The service is rendered to an Ohio-medicaid-eligible individual in a state in which the APRN is licensed or authorized to practice;

(b) The service is within the scope of practice of the APRN's specialty;

(c) The APRN personally rendered the service to an individual patient; and

(d) The service cannot be performed by someone who lacks the skills and training of an APRN.

(C) Payment.

(1) Payment for a covered service rendered by a CRNA is made in accordance with rule 5160-4-21 of the Administrative Code.

(2) Payment for a covered service rendered by a CNS, CNM, or CNP is the lesser of the billing provider's submitted charge or the applicable amount from the following list:

(a) For a covered service rendered in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), eighty-five per cent of the medicaid maximum;

(b) For a covered service rendered in a non-hospital setting, one hundred per cent of the medicaid maximum; or

(c) For assistant-at-surgery services provided by a CNS, CNM, or CNP regardless of setting, twenty-five per cent of the medicaid maximum for the covered primary surgical procedure.

(3) Payment for services rendered by a hospital-employed APRN will be made to the hospital.

(4) In the event that payment for a covered service performed by an APRN is issued both to the APRN and to a contracting or supervising provider on behalf of the APRN, one of the issued payments is subject to recovery.

Last updated January 3, 2022 at 9:48 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2027
Prior Effective Dates: 5/12/1994, 4/1/2018

Rule 5160-4-06 | Specific provisions for evaluation and management (E&M) services.

• Effective: January 1, 2024
• Promulgated Under: 119.03

(A) Site-related provisions. Policies concerning payment for evaluation and management (E&M) services may depend on the site in which the services are provided.

(1) Ambulance. Policies for E&M services provided during ambulance transport by hospital staff members are set forth in rule 5160-2-04 of the Administrative Code. Payment for E&M services provided during ambulance transport by practitioners who are not hospital staff members is subject to the following conditions:

(a) Such services involve direct face-to-face contact between a practitioner and the individual being transported, which begins when the practitioner assumes responsibility for the care of the individual at the point of pickup and ends when the receiving facility assumes this responsibility. Remote direction of emergency care en route (e.g., communication by radio with a physician located in a hospital) is not direct face-to-face contact.

(b) Routine monitoring and maintenance (e.g., the recording of vital information, pulse oximetry, the initiation of mechanical ventilation) is included; no separate payment is made.

(c) Services provided by other members of the transport team (the ambulance crew) cannot be reported by the practitioner as E&M services.

(2) Nursing facility (NF). Policies are set forth in Chapter 5160-3 of the Administrative Code. The periodic review of a NF resident's medical record, plan of care, or habilitation plan is part of overall medical direction, payment for which is made to the NF rather than to the practitioner.

(3) Federally qualified health center, outpatient health facility, or rural health clinic. Policies are set forth in Chapter 5160-28 of the Administrative Code. Specific claim formats may apply.

(B) Service-related provisions.

(1) After-hours care. Additional payment may be made for E&M services provided in a non-hospital setting after regularly scheduled business hours.

(2) Bundled services. No separate payment is made for E&M services provided in conjunction with certain covered diagnostic or therapeutic procedures, which are identified in other rules in Chapter 5160-4 of the Administrative Code.

(3) Consultation. Payment may be made for a consultation provided by a licensed medical practitioner regarding the evaluation and management of a specific medical problem.

(a) A licensed medical practitioner enrolled as a medicaid provider requests the consultation. For purposes of this rule, a medical visit initiated by someone other than a licensed medical practitioner (e.g., a patient, a family member, a teacher, a social worker) is not a consultation.

(b) The request for a consultation, the need for a consultation, the consultant's opinion, and any services that were ordered or performed in relation to the consultation are documented in the patient's medical record.

(c) Follow-up visits initiated by a consultant for the purpose of evaluation and management of a patient's condition are E&M services rather than consultation.

(d) The referring practitioner is identified on any claim for consultation that is submitted.

(4) Critical-care services. Payment for covered critical-care services provided by a single practitioner is limited to two hours per patient per day. This time limit does not apply to critical-care services rendered during the transportation of a critically ill or injured individual older than twenty-four months.

(5) Hospital observation services (including admission and discharge services). Payment may be made for not more than twenty-two hours of medical observation of an individual who is treated in a hospital but does not need to be admitted as an inpatient.

(a) Emergency department services are not observation.

(b) If during observation the individual is admitted to the hospital as an inpatient, payment for the observation services depends on the role of the practitioner.

(i) If the observing practitioner continues as the individual's attending practitioner after admission, the observation services are treated as inpatient E&M services and are reported as such on any claim submitted.

(ii) If the observing practitioner does not continue as the individual's attending practitioner after admission, the observation services are not reported as inpatient E&M services.

(6) Inpatient hospital visits following surgery. No separate payment is made for an E&M service provided within the postoperative period for a covered surgical procedure. The postoperative period, which is listed in appendix DD to rule 5160-1-60 of the Administrative Code, includes the day of surgery. The postoperative period for one surgical procedure may be extended by the performance soon afterward of another surgical procedure.

(7) Medication-assisted treatment, which is defined at 42 C.F.R. 8.2 (October 1, 2023). Separate payment may be made for the provision of self-administered take-home medication for the treatment of substance use disorder, in addition to an E&M service, if the following conditions are met:

(a) The provider complies with all applicable rules and requirements of the United States drug enforcement administration, the Ohio board of pharmacy, and the Ohio state medical board;

(b) The medication is a pharmaceutical prescribed for the treatment of opioid addiction; and

(c) The provider includes in the patient's medical record documentation that the amount of take-home medication provided was medically necessary.

(C) Limitations.

(1) Payment for an E&M service that is not medically necessary in accordance with rule 5160-1-01 of the Administrative Code is subject to recovery.

(2) Concurrent care is the provision of service to one individual on one date of service by more than one practitioner in the same group practice. When concurrent care is provided, payment may be made only for one E&M service (i.e., the separate services are treated as though they were provided by the same practitioner for the same purpose) unless one of the following conditions applies:

(a) The services were provided for unrelated purposes;

(b) The practitioners had different specialties; or

(c) Each practitioner supplied knowledge or skill the other practitioners could not provide.

(3) E&M services in excess of twenty-four during a calendar year that are provided to an individual in an outpatient setting or a NF are subject to post-payment review. The following services are excluded from the calculation of the number of E&M services provided during a calendar year:

(a) Pregnancy-related services, which are described in rule 5160-21-04 of the Administrative Code;

(b) Early and periodic screening, diagnostic, and treatment (EPSDT) services;

(c) Inpatient hospital visits;

(d) Critical-care visits;

(e) An allergen immunotherapy service that is not provided in conjunction with an E&M service; and

(f) An E&M service provided for any of the following conditions or purposes:

(i) End-stage renal disease;

(ii) Chemotherapy or radiation therapy for malignancy;

(iii) End-stage lung disease;

(iv) Unstable diabetes or diabetes with complications;

(v) Uncontrolled hypertension or hypertension with complications;

(vi) Neoplasms or leukemia;

(vii) Organ transplantation;

(viii) Hereditary anemias;

(ix) Hemophilia or other congenital disorders of clotting factors;

(x) Acquired hemolytic anemias;

(xi) Aplastic anemias;

(xii) Deficiency of humoral immunity;

(xiii) Deficiency of cell-mediated immunity;

(xiv) Combined immunity deficiency;

(xv) Cystic fibrosis;

(xvi) Malabsorption;

(xvii) Failure to thrive;

(xviii) Infant prematurity;

(xix) Respiratory distress syndrome or other respiratory conditions of the fetus or newborn; or

(xx) The terminal stage of any life-threatening illness.

Last updated January 2, 2024 at 9:40 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2029
Prior Effective Dates: 10/1/1983 (Emer.), 1/1/1986, 5/9/1986, 2/17/1991, 7/1/1992, 12/31/1992 (Emer.), 12/31/1997 (Emer.), 3/20/2000, 3/20/2001, 1/2/2004 (Emer.), 3/20/2005, 12/31/2008 (Emer.), 12/31/2012 (Emer.), 9/1/2013

Rule 5160-4-12 | Immunizations, injections and infusions (including trigger-point injections), skin substitutes, and provider-administered pharmaceuticals.

• Effective: March 1, 2022
• Promulgated Under: 119.03

(A) General provisions.

(1) A "not otherwise specified," "unlisted," or "miscellaneous" procedure code should be reported on a claim only if no procedure code is available that identifies the particular service or item provided.

(2) No separate payment is made for an immunization, injection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provided in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department).

(3) A provider-administered pharmaceutical reported on a claim submitted in accordance with Chapter 5160-9 of the Administrative Code is regarded as a pharmacy service rather than a professional medical service, and payment of the claim is governed by the provisions of that chapter. For example, a vaccine, toxoid, or other provider-administered pharmaceutical prescribed for a resident of a long-term care facility (LTCF) and subsequently administered by a LTCF staff member is a pharmacy service.

(4) Payment for an immunization, injection, or infusion includes related supplies (e.g., alcohol wipes, needles, syringes, and tubing).

(B) Coverage of immunizations. An immunization has two components: the administration of the vaccine or toxoid and the vaccine or toxoid itself.

(1) Payment for administration may take one of two forms:

(a) Payment for the most appropriate administration procedure; or

(b) Payment for the least complex evaluation and management service rendered to an established patient.

(2) Separate payment may be made for the vaccine or toxoid. No payment, however, will be made for vaccines that can be obtained at no cost through the federal vaccines for children (VFC) program, which is administered by the Ohio department of health (ODH).

(3) Limitations apply to certain vaccines.

(a) Regardless of the formulation, payment for hepatitis B vaccine (HBV) administered to individuals younger than nineteen years of age may be made only under the VFC program. Different procedure codes are reported on claims to distinguish HBV administered to individuals younger than nineteen from HBV administered to individuals nineteen or older.

(b) Vaccines for the human papilloma virus (HPV) are covered in accordance with the schedule regarding the appropriate periodicity, dosage, and contraindications applicable to vaccines established by the advisory committee on immunization practices of the centers for disease control and prevention, available from http://www.cdc.gov.

(C) Coverage of therapeutic, prophylactic, or diagnostic injections or infusions (excluding chemotherapy and other complex procedures).

(1) An injection or infusion has two components: the administration of a fluid medium and, except in the case of hydration, the pharmaceutical itself. No separate payment is made for the administration service if an injection or infusion is given during the course of an office visit or in conjunction with another medical service that includes an evaluation and management element.

(2) Payment may be made for an injection or infusion or a provider-administered pharmaceutical only if at least one of the following criteria is met:

(a) Its use for a particular indication has been approved by the U.S. food and drug administration; or

(b) According to accepted standards of medical practice, it is a specific or effective treatment for the particular condition for which it is given.

(3) No separate payment is made for an injection or infusion or a provider-administered pharmaceutical that meets either of the following criteria:

(a) The frequency or duration of its administration exceeds accepted standards of medical practice for the particular condition; or

(b) It is provided for or in association with non-covered medicaid services, which are defined in rule 5160-1-61 of the Administrative Code.

(4) Immune globulin is covered when it is used to provide passive immunity to an individual who is immunosuppressed; has an acquired or congenital immunodeficiency; is at risk of Rh-isoimmunization; or is in immediate danger of contracting a communicable disease through direct contact with blood, saliva, or other body fluids through an open wound, bite, puncture, or mucous membrane.

(5) Epoetin alfa (EPO) for the treatment of anemia, either associated with or not related to chronic renal failure, is covered as a medical service when a provider incurs the cost of the drug and the service is provided in a dialysis center or office setting.

(6) Certain procedure codes represent a specific number of dosage units. On a claim, the fewest number of procedure codes are to be reported together to represent the administered dosage.

(D) Coverage of trigger-point injections.

(1) A trigger point is a hyperexcitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Payment may be made for a trigger-point injection only if the following criteria are met:

(a) The patient has a diagnosis for which the trigger-point injection is an appropriate treatment; and

(b) The following information is documented in the patient's medical record:

(i) A proper evaluation including a patient history and physical examination leading to diagnosis of the trigger point;

(ii) The reason or reasons for selecting this therapeutic option;

(iii) The affected muscle or muscles;

(iv) The muscle or muscles injected and the number of injections;

(v) The frequency of injections required;

(vi) The name of the medication used in the injection;

(vii) The results of any prior treatment; and

(viii) Corroborating evidence that the injection is medically necessary.

(2) A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed.

(3) Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date.

(4) Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. For trigger-point injections of a local anesthetic or a steroid, payment will be made for no more than eight dates of service per calendar year per patient.

(E) Coverage of skin substitutes.

(1) Skin substitutes may be used on burns or ulcers when grafting with actual skin is not an appropriate option. Skin substitutes are expected to function as a permanent replacement for lost or damaged skin. They may be used for temporary wound coverage or wound closure as appropriate and medically necessary. Payment may be made for a skin substitute if a practitioner determines that the skin substitute will be of benefit for the particular type of wound.

(a) When a skin substitute is applied in an office setting, payment may be made to a practitioner for both the skin substitute and an appropriate skin application procedure.

(b) When a skin substitute is applied in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department), payment may be made to a practitioner only for the skin application procedure. Payment for the skin substitute is included in the hospital's facility payment.

(c) When a skin substitute is applied in a long-term care facility (LTCF), payment may be made to a practitioner for the skin application procedure. Payment for the skin substitute may be made to the practitioner only if the practitioner supplies the skin substitute; otherwise, payment for the skin substitute is included in the LTCF's facility payment.

(2) The results of treatment are to be documented in the individual's medical record. Payment will not be made for additional applications or re-applications if the wound volume has not decreased by at least fifty per cent after three separate treatments over twelve weeks.

(F) Payment.

(1) On the department's web site, http://medicaid.ohio.gov, is a list of vaccines, toxoids, skin substitutes, and other provider-administered pharmaceuticals each of which is covered by medicaid either as a medical service or as a VFC-designated vaccine. Payment for a covered non-VFC vaccine, toxoid, skin substitute, or other provider-administered pharmaceutical is the lesser of the provider's submitted charge or the first applicable item from the following ordered list:

(a) An amount specified in or determined in accordance with the Administrative Code;

(b) The state maximum allowable cost (SMAC), which is defined in rule 5160-9-05 of the Administrative Code;

(c) The payment limit shown in the current medicare part B drug pricing file, which is available at http://www.cms.gov;

(d) One hundred seven per cent of the wholesale acquisition cost (WAC); or

(e) Eighty-five and six-tenths per cent of the average wholesale price (AWP).

(2) Payment for any other covered administration service or evaluation and management service listed in appendix DD to rule 5160-1-60 of the Administrative Code is made in accordance with that rule.

Last updated March 1, 2022 at 8:32 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 3/1/2027
Prior Effective Dates: 12/21/1977, 1/8/1979, 9/20/1984 (Emer.), 5/25/1991, 3/19/1992, 12/30/1992 (Emer.), 3/30/1995, 12/31/1997 (Emer.), 12/31/1998 (Emer.), 3/20/2000, 3/30/2001, 1/1/2007, 7/1/2008, 11/13/2008, 12/29/2009, 4/28/2010 (Emer.), 12/30/2010 (Emer.), 8/2/2011, 12/31/2012 (Emer.), 11/1/2015

Rule 5160-4-14 | Professional services associated with dialysis.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(A) Routine maintenance dialysis.

(1) Payment for professional services associated with the medical management of patients receiving maintenance dialysis is made either on a monthly capitation basis or on a daily basis.

(a) The monthly capitation payment is available to a single practitioner in the following circumstances:

(i) The practitioner alone provides monthly continuity of services to a single patient or to a group of patients; or

(ii) The practitioner serves as the primary practitioner in a joint provision (in which one person receives payment on behalf of a team of practitioners).

(b) When dialysis care is provided by more than one practitioner in the absence of a joint provision, payment may be made to each practitioner separately for the days on which dialysis care was provided.

(c) On a submitted claim, the type of service payment (monthly capitation or daily care) is differentiated by procedure code.

(2) In addition to the payment for professional services, separate payment may be made for the following services:

(a) The declotting of shunts; and

(b) Covered professional services that are unrelated to the patient's dialysis or renal condition.

(B) Inpatient dialysis services.

(1) Payment may be made for professional services that are related to dialysis performed for a hospital inpatient for one of the following reasons:

(a) Treatment of acute renal failure or renal trauma;

(b) Establishment of an initial course of dialysis (the first dialysis treatment and all subsequent dialysis treatments performed before the patient is stabilized on dialysis); or

(c) Treatment of an established dialysis patient who was admitted to the hospital for a condition or illness unrelated to the patient's renal condition.

(2) The following provisions apply to payment for professional services related to inpatient dialysis:

(a) The time when the practitioner is present with the patient during the dialysis procedure is documented in the patient's medical record.

(b) On a submitted claim, an appropriate procedure code is used to indicate inpatient dialysis care.

(c) Payment for professional services includes all evaluation and management services related to the patient's renal condition. (The payment to the hospital for inpatient dialysis includes all other patient care services that are rendered during the dialysis procedure.)

(d) If a dialysis patient is admitted to a hospital for no reason other than to receive maintenance dialysis, the dialysis is considered to be routine maintenance and payment for professional services is made accordingly.

(C) For services rendered to a single patient in a single calendar month, the following overpayments or duplicate payments are disallowed:

(1) More than one monthly capitation payment;

(2) Payment for more than thirty-one days of daily dialysis care; and

(3) Both the monthly capitation payment and payment for daily dialysis care.

Last updated July 1, 2021 at 9:53 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 3/31/2009

Rule 5160-4-19 | Allergy services.

• Effective: May 1, 2021
• Promulgated Under: 119.03

(A) Purpose. This rule addresses payment for the professional administration and evaluation of allergy sensitivity test procedures, which can be divided into three categories: allergy testing, ingestion challenge testing, and allergen immunotherapy. Payment for related laboratory tests is addressed in Chapter 5160-11 of the Administrative Code.

(B) Coverage.

(1) Allergy testing.

(a) Testing is only appropriate if there is a reasonable probability, documented in the individual's medical file, that the individual was exposed to the antigen being used for the test.

(b) The unit of service is the test. Payment may be made only for the fewest number of tests necessary to reach a diagnosis.

(c) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(d) A qualitative multiallergen screen for allergen-specific immunoglobulin E (IgE) is not considered to be medically necessary.

(2) Ingestion challenge testing.

(a) The unit of service is the encounter. Payment may be made only once per visit regardless of the number of items tested.

(b) Payment includes the evaluation of the individual's response to the test items.

(3) Allergen immunotherapy.

(a) Payment includes all associated professional services. No payment is made for evaluation and management unless a separately identifiable service is performed.

(b) Payment for the antigen is made separately. No payment will be made for a service that includes administration (injection) as well as the antigen and its preparation.

(c) The unit of service is the dose-per-vial.

(d) Separate payment for the preparation of a single-dose vial of allergen antigen may be made only if the provider prepares the antigen for injection by another entity.

(e) The date of service is the date on which the first dose is administered or the date on which the vial is dispensed for future use.

(f) Immunotherapy is not considered to be medically necessary for an allergic reaction to common environmental factors (such as dust, house plants, or natural fibers) that can be mitigated by other means.

Last updated May 1, 2021 at 9:06 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 5/1/2026
Prior Effective Dates: 4/1/1993, 1/1/2001

Rule 5160-4-20 | Chemotherapy.

• Effective: January 1, 2020
• Promulgated Under: 119.03

(A) Chemotherapy has two components: administration of a chemotherapeutic agent and the chemotherapeutic agent itself. The administration of chemotherapy includes the preparation of the chemotherapeutic agent and all therapeutic services and medical supplies provided during treatment.

(B) Coverage.

(1) Chemotherapy provided in a hospital setting (inpatient hospital, outpatient hospital, emergency department) is a hospital service, for which payment is made in accordance with Chapter 5160-2 of the Administrative Code. No separate payment is made to a practitioner for either chemotherapy administration or a chemotherapeutic agent provided in a hospital setting.

(2) Separate payment may be made for chemotherapy administration that is provided in a non-hospital setting by a practitioner (such as an oncologist) or by a qualified employee supervised by a practitioner. Any place-of-service restriction on this provision is shown in appendix DD to rule 5160-1-60 of the Administrative Code.

(3) Separate payment may be made for a chemotherapeutic agent that is furnished by a practitioner, represents a cost to the practitioner, and is administered in a non-hospital setting.

(4) The process of supervising and monitoring chemotherapy treatment is included in an evaluation and management service (office visit). The actual administration of chemotherapy, however, is a professional service that is independent of evaluation and management. Separate payment may be made for evaluation and management provided in conjunction with chemotherapy administration in a non-hospital setting.

Last updated February 7, 2024 at 9:21 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 2/2/2029
Prior Effective Dates: 7/1/1992, 8/2/2011

Rule 5160-4-21 | Anesthesia services.

• Effective: January 1, 2024
• Promulgated Under: 119.03

(A) Scope and definitions.

(1) This rule sets forth provisions governing payment for the administration or management of anesthesia as a non-institutional professional service rendered by qualified medical practitioners. Provisions governing payment for anesthesia as a dental service are set forth in Chapter 5160-5 of the Administrative Code.

(2) "Base unit" is an anesthesia-related component representing factors other than an anesthetist's time, such as standard pre-operative and post-operative visits, the administration of fluids or blood incident to anesthesia administration, and monitoring.

(3) "Base unit value" is the value for a base unit assigned by the centers for medicare and medicaid services (CMS). A table of procedure codes and their respective base unit values is available from the CMS web site, https://www.cms.gov.

(4) "Time unit" is an anesthesia-related component representing the span, reported in minutes, during which an anesthesiologist or a medically-directed or medically-supervised qualified non-physician anesthetist is continuously present. The measured length of the time unit depends on the type of anesthesia.

(a) For neuraxial labor analgesia, the time unit begins when the analgesic is inserted and ends at delivery. Total duration is limited to two hundred forty minutes (four hours).

(b) For all other anesthesia, the time unit begins when the anesthetist starts to prepare the individual for the induction of anesthesia and ends when the presence of the anesthetist is no longer required and the individual may be safely placed under post-anesthetic care.

(5) "Time unit value" is the number of fifteen-minute increments in a time unit, rounded to the nearest tenth.

(B) Providers.

(1) Rendering providers. The following eligible medicaid providers may administer anesthesia:

(a) An anesthesiologist (i.e., a physician trained in anesthesia);

(b) A certified registered nurse anesthetist (CRNA); or

(c) An anesthesiologist assistant (AA).

(2) Billing providers. The following eligible medicaid providers may receive medicaid payment for submitting a claim for administering anesthesia:

(a) An anesthesiologist;

(b) A CRNA;

(c) A professional medical group; or

(d) An AA.

(C) Coverage.

(1) Payment may be made for the following procedures or activities as anesthesia services:

(a) Procedures performed during a surgical or diagnostic procedure:

(i) Administration of general anesthesia;

(ii) Administration of regional anesthesia;

(iii) Supplementation of local anesthesia;

(iv) Administration of post-operative pain block procedures separately from anesthesia;

(v) Provision of monitored anesthesia care (MAC); and

(vi) Performance of unusual monitoring procedures such as cardiovascular catheterization (e.g., intra-arterial, central venous, Swan-Ganz);

(b) Administration of obstetrical anesthesia for either of two purposes:

(i) Neuraxial analgesia for vaginal delivery (including repeated subarachnoid needle placement, drug injection, and necessary epidural catheter replacement during labor); or

(ii) Anesthesia for cesarean delivery; and

(c) Provision of medical direction or supervision by an anesthesiologist.

(2) No separate payment is made for the following services, which are considered to be part of anesthesia administration:

(a) Routine pre-operative and post-operative visits;

(b) Anesthesia care during the procedure;

(c) The administration of fluid or blood products incident to the anesthesia or surgery; and

(d) Usual monitoring procedures (e.g., electrocardiography, the taking of body temperature, the recording of blood pressure, oximetry, capnography, mass spectometry).

(D) Allowances and limitations.

(1) Payment may be made on a case-by-case basis for two anesthesia services provided to one individual on a single date of service only if at least one of the following conditions applies:

(a) Between the two surgical or diagnostic procedures, the individual either was released from the recovery area to the floor (or intensive care unit) or was discharged from the hospital;

(b) After completion of the surgical or diagnostic procedure, the individual had to return for a follow-up procedure on an emergency basis;

(c) It was medically necessary for two surgical or diagnostic procedures to be performed separately, and two separate anesthetics were required; or

(d) Anesthesia was administered both for a delivery and separately for a tubal ligation meeting the requirements specified in Chapter 5160-21 of the Administrative Code.

(2) In all other cases, payment may be made only for one anesthesia service provided to one individual on a single date of service.

(3) Payment for anesthesia services may be made to an anesthesiologist only if all of the following conditions are met:

(a) The anesthesiologist acts exclusively as an anesthetist and does not also act as a surgeon or assistant surgeon;

(b) The anesthesiologist completes the following tasks in preparation for anesthesia administration:

(i) Performing a pre-anesthetic examination and evaluation or, for obstetrical anesthesia, performing or approving a pre-anesthetic examination and evaluation for labor analgesia provided by a qualified anesthetist; and

(ii) Prescribing an anesthesia plan or, for obstetrical anesthesia, prescribing or approving an anesthesia plan.

(c) For each individual patient, the anesthesiologist carries out the following activities:

(i) Personally participating in the most demanding parts of the anesthesia plan, including induction and emergence or, for obstetrical anesthesia, personally participating in all critical portions of the procedure (e.g., needle placement for neuraxial analgesia);

(ii) Ensuring that any procedures in the anesthesia plan that the anesthesiologist does not perform are performed by a qualified individual;

(iii) Monitoring the course of anesthesia administration at frequent intervals or, for obstetrical anesthesia, periodically monitoring the course of anesthesia or analgesia administration or ensuring that a qualified anesthetist performs the monitoring;

(iv) Remaining physically present and available for immediate diagnosis and treatment in case of emergency or, for obstetrical anesthesia, remaining readily available for immediate diagnosis and treatment in case of emergency; and

(v) Providing indicated post-anesthetic care.

(4) Payment for medical direction may be made to an anesthesiologist if the anesthesiologist delegates some or all of the activities listed in paragraphs (D)(3)(b) and (D)(3)(c) of this rule to not more than four qualified non-physician anesthetists performing concurrent anesthesia procedures.

(5) Payment for medical supervision may be made to an anesthesiologist if the following conditions are met:

(a) For obstetrical anesthesia, the anesthesiologist delegates some or all of the activities listed in paragraph (D)(3)(c) of this rule to qualified non-physician anesthetists, and the anesthesiologist supervises one of the following activities:

(i) A critical portion of more than four concurrent obstetrical anesthesia procedures (e.g., needle placement for neuraxial analgesia);

(ii) A critical portion of an obstetrical anesthesia procedure along with more than four concurrent surgical anesthesia procedures; or

(iii) A critical portion of an obstetrical anesthesia procedure while the anesthesiologist is not physically present in the obstetrical suite.

(b) For all other anesthesia, the anesthesiologist delegates some or all of the activities listed in paragraph (D)(3)(c) of this rule to more than four qualified non-physician anesthetists performing concurrent anesthesia procedures.

(6) In addition to payment for surgical procedures, a surgeon or a group practice of surgeons is permitted to receive payment for anesthesia services provided by a CRNA who is employed by the surgeon or group practice.

(7) The services of a CRNA or AA employed by a hospital are considered to be hospital services, payment for which is made to the hospital.

(E) Claim payment.

(1) Payment for an anesthesia service is the lesser of the provider's submitted charge or the medicaid maximum, which is determined by a formula.

(a) The amount is the product of three factors:

(i) The sum of the base unit value and the time unit value;

(ii) The appropriate conversion factor; and

(iii) The relevant multiplier.

(b) Conversion factors and multipliers are listed in the appendix to this rule.

(c) For daily management of epidural or subarachnoid drug administration, the time unit value is zero.

(2) No additional payment will be made on account of physical status, age, body temperature (hypothermia or hyperthermia), emergency conditions, or time of day.

View Appendix

Last updated January 2, 2024 at 8:54 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2029
Prior Effective Dates: 5/9/1986, 1/13/1989 (Emer.), 7/24/1994, 12/31/1996 (Emer.)

Rule 5160-4-22 | Surgical services.

• Effective: January 1, 2022
• Promulgated Under: 119.03

(A) Coverage.

(1) In general, payment may be made to an eligible provider for performing a medically necessary surgical procedure on a medicaid-eligible individual. The following limitations, however, apply.

(a) No separate payment is made to the provider of a surgical service for local infiltration, the administration of general anesthesia or sedation, normal uncomplicated preoperative and postoperative care, or any procedure that is performed incidental to or as an integral part of the operation. On claims, providers should report comprehensive surgical services; they are not to itemize or "unbundle" individual components.

(b) Certain characteristics of a surgical procedure performed on the same patient by the same provider may affect how it is reported on a claim and how payment for it is made.

(i) The Ohio department of medicaid (ODM) recognizes five groups of surgical procedures defined by a particular characteristic:

(a) Multiple procedures, for which payment is reduced when more than one is performed;

(b) Bilateral procedures, for which payment is adjusted when they are performed on both body parts of a corresponding pair;

(c) Co-surgery procedures, for which payment is split between two surgeons, each in a different specialty, who perform parts of the same procedure simultaneously.

(d) Assistant-at-surgery procedures, for which payment is reduced when they are performed by an assistant at surgery; and

(e) Procedures performed on fingers, toes, eyelids, or coronary arteries.

(ii) In assigning covered procedures to these groups, ODM follows the policies of the medicare program except when otherwise noted in this rule.

(2) Payment may be made for a co-surgery procedure only if the following conditions are met:

(a) The procedure can be performed only by surgeons;

(b) Not more than two surgeons submit a claim for the procedure; and

(c) Manual review of supporting documentation is not necessary to establish the need for two surgeons.

(3) Payment for an assistant-at-surgery procedure is subject to the following constraints:

(a) No additional payment is made for the services of more than one assistant at surgery during an operation, regardless of the extent of the surgery;

(b) Payment may be made for an assistant-at-surgery procedure performed in a teaching hospital only if at least one of the following conditions is met:

(i) The surgeon who performed the assistant-at-surgery procedure was neither a resident nor an intern, and this fact is attributable to either of the following reasons:

(a) The primary surgeon does not customarily use residents or interns for any part of the particular surgical procedure (including preoperative and postoperative care); or

(b) No resident in a training program in a medical specialty appropriate to the surgical procedure was available to serve as an assistant at surgery.

(ii) The assistant-at-surgery procedure constituted concurrent care for a medical condition that necessitated active treatment during surgery by physicians of more than one specialty;

(iii) During surgery, complex medical procedures were performed that involved a team of physicians; or

(iv) Exceptional medical circumstances warranted an assistant at surgery.

(4) Payment for physician visits in addition to surgery is addressed in rule 5160-4-06 of the Administrative Code.

(5) Certain types of surgery are often supplemented by the use of a cast, splint, strap, or other traction device. For initial application and removal that is performed in conjunction with covered musculoskeletal surgery, payment for the surgery includes the application and removal procedures, all materials (casting components, splints, or straps), and incidental supplies. In all other circumstances, the following provisions apply:

(a) Payment for the work depends on the nature and purpose of the procedure.

(i) For initial application and removal that is not performed in conjunction with surgery (e.g., the casting or strapping of a sprained joint), payment may be made for an appropriate evaluation and management service;

(ii) For necessary replacement, payment may be made for an appropriate casting/strapping procedure; and

(iii) For necessary repair, payment may be made for an appropriate evaluation and management service.

(b) Separate payment may be made for materials only if the service was rendered in a non-hospital setting.

(c) No separate payment is made for incidental supplies.

(B) Claim payment. Payment for a surgical procedure is the lesser of two figures:

(1) The provider's submitted charge; or

(2) A percentage of the medicaid maximum amount specified in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule, determined in the following manner:

(a) For a procedure that is not performed incidental to or as an integral part of an operation and that is not subject to multiple-procedure payment reduction, one hundred per cent;

(b) For a procedure that is subject to multiple-procedure payment reduction, the relevant percentage from the following list:

(i) For a primary procedure (i.e., the procedure with the highest maximum amount listed in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule), one hundred per cent;

(ii) For a secondary procedure (i.e., the procedure with the next highest maximum amount listed in rule 5160-1-60 of the Administrative Code or in appendix DD to that rule), fifty per cent; or

(iii) For any other procedure, twenty-five per cent;

(c) For a co-surgery procedure, sixty two and a half per cent per surgeon;

(d) For a bilateral procedure, one hundred fifty per cent; or

(e) For an assistant-at-surgery procedure, twenty-five per cent.

Last updated January 3, 2022 at 9:49 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2027
Prior Effective Dates: 10/1/1983 (Emer.), 12/29/1983, 1/13/1989 (Emer.), 9/1/1989, 3/29/2007, 3/30/2008, 12/6/2010, 3/30/2011, 12/30/2011 (Emer.), 3/29/2012, 7/3/2015

Rule 5160-4-23 | Covered ambulatory surgery center (ASC)surgical procedures.

• Effective: January 1, 2024
• Promulgated Under: 119.03

(A) Payment may be made to an ambulatory surgery center (ASC) in the form of a facility fee only for covered ASC surgical procedures, which are procedures that meet the standards set forth in 42 CFR 416.166 (October 1, 2017). Such procedures are listed on the department's website https://medicaid.ohio.gov/resources-for-providers/billing/fee-schedule-and-rates/fee-schedule-and-rates.

(B) Payment may be made to a physician for performing a covered surgical procedure in an ASC even if the surgery is not itself a covered ASC surgical procedure.

(C) Payment may be made to a physician for performing the professional component of a covered laboratory, radiologic, diagnostic, or therapeutic service in an ASC only if the physician personally performed the service and was not an employee of the ASC at the time.

Last updated January 2, 2024 at 8:54 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/1/2029
Prior Effective Dates: 12/29/1995 (Emer.), 3/21/1996, 1/1/2001, 7/1/2009

Rule 5160-4-25 | Radiology and imaging services.

• Effective: November 1, 2021
• Promulgated Under: 119.03

(A) Coverage.

(1) Total (global) procedure. Payment may be made to a practitioner for performing both the professional and technical components of a radiology or imaging procedure if two conditions are met:

(a) The technical component was not performed in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or a hospital emergency department); and

(b) The practitioner who submitted the claim either performed the professional component or has an employment or written contractual arrangement with the practitioner who performed the professional component.

(2) Technical component. Payment may be made to a practitioner for performing only the technical component of a radiology or imaging procedure if three conditions are met:

(a) The professional component was performed by another practitioner;

(b) The technical component was not performed in a hospital setting; and

(c) The practitioner who submitted the claim either performed the technical component or employs the practitioner who performed the technical component.

(3) Professional component.

(a) Payment may be made to a practitioner for performing only the professional component of a radiology or imaging procedure if the professional component represents either of two services:

(i) The initial interpretation of the result of a radiology or imaging procedure; or

(ii) The interpretation by a specialist of the result of a radiology or imaging procedure that has already been interpreted by another practitioner (e.g., a treating physician).

(b) No payment is made for the interpretation by a non-specialist of the result of a radiology or imaging procedure that has already been interpreted by a specialist.

(4) Mammography services.

(a) Payment for screening mammography may be made at the following frequencies:

(i) For an individual who is at least thirty-five years of age but less than forty, once; and

(ii) For an individual who is at least forty years of age, once per twelve months.

(b) Payment for diagnostic mammography may be made for an individual, regardless of age, who shows clinical symptoms of breast cancer or who is at high risk for developing breast cancer.

(5) No separate payment is made for supplies used in connection with a radiology or imaging procedure performed in a hospital setting.

(6) No separate payment is made for conscious sedation administered in connection with a radiology or imaging procedure.

(B) Claim payment.

(1) For a covered radiology or imaging procedure or radiology or imaging procedure component performed by a non-hospital provider, payment is the lesser of the submitted charge or the product of the following two figures:

(a) The maximum payment amount listed in appendix DD to rule 5160-1-60 of the Administrative Code; and

(b) The relevant percentage indicated by the 'prof/tech split' entry listed in appendix DD to rule 5160-1-60 of the Administrative Code (or one hundred per cent if no entry is listed).

(2) If more than one advanced imaging procedure (e.g., computed tomography, magnetic resonance imaging, ultrasound) is performed by the same provider or provider group for an individual patient in the same session, then the procedure with the highest payment amount specified in appendix DD to rule 5160-1-60 of the Administrative Code is considered to be the primary procedure. The payment amount for a covered advanced imaging procedure is the lesser of the 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:

(a) For a primary procedure, it is one hundred per cent.

(b) For each additional total procedure, it is fifty per cent.

(c) For the technical component alone of each additional procedure, it is fifty per cent.

(d) For the professional component alone of each additional procedure, it is ninety-five per cent.

Last updated November 1, 2021 at 3:11 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 11/1/2026
Prior Effective Dates: 10/1/1983 (Emer.), 1/13/1989 (Emer.), 9/1/1989, 7/1/1994, 12/30/1994 (Emer.), 7/1/1996, 3/19/1998, 7/1/2003, 9/1/2005, 8/2/2011

Rule 5160-4-33 | Application of topical fluoride varnish by non-dentist providers.

• Effective: May 1, 2021
• Promulgated Under: 119.03

(A) Payment may be made not more frequently than once per one hundred eighty days for the topical application of fluoride varnish to the teeth of a child younger than six years of age by any of the following practitioners:

(1) A physician;

(2) A physician assistant; or

(3) An advanced practice registered nurse.

(B) As part of the application of fluoride varnish, a practitioner provides three related services:

(1) An oral assessment for the identification of obvious oral health problems and risk factors, which may be omitted if an oral assessment is conducted or has been conducted during an early and periodic screening, diagnostic, and treatment (EPSDT) visit;

(2) Communication with the parent or guardian about the fluoride varnish procedure and proper oral health care for the child; and

(3) If the child has obvious oral health problems and does not have a dental provider, referral to a dentist or to the county department of job and family services.

(C) Payment for the application of fluoride varnish is made separately from payment for a well child visit or a sick child visit.

Last updated May 1, 2021 at 9:03 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 5/1/2026
Prior Effective Dates: 12/31/2012 (Emer.)