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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Chapter 5160-7 | Podiatric Services

 
 
 
Rule
Rule 5160-7-01 | Podiatry services.
 

(A) For the purpose of this rule the following definitions apply.

(1) "Doctor of podiatric medicine" (or "podiatric physician" or "podiatrist") is as described in section 4731.51 of the Revised Code.

(a) Doctors of podiatric medicine are deemed to be physicians only in respect to functions they are legally authorized to perform in accordance with section 4731.51 of the Revised Code and rule 4731-20-02 of the Administrative Code.

(b) For purposes of medicaid coverage and payment, an intern or resident of podiatric medicine is not a podiatric physician. This exclusion applies even if an intern or resident is authorized to practice as a podiatric physician under the laws of the state in which services are performed or a resident holds a staff or faculty appointment or is designated as a fellow. For purposes of medicaid coverage and payment, an intern or resident of podiatric medicine is not a podiatric physician.

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

(B) Coverage.

(1) Services and procedures performed by a doctor of podiatric medicine that are within the scope of practice of a podiatric physician are considered to be physician services. They are subject to and are covered in accordance with applicable medicaid rules in the Administrative Code concerning physician services.

(2) The services of interns and residents of podiatric medicine rendered in a hospital setting are covered as hospital services in accordance with Chapter 5160-2 of the Administrative Code.

(3) Podiatric medicine services provided by a physician assistant are covered in accordance with rule 5160-4-03 of the Administrative Code.

(4) Podiatric medicine services provided by an advanced practice registered nurse are covered in accordance with rule 5160-4-04 of the Administrative Code.

(C) Constraints and limitations.

(1) A "by report" podiatric medicine service or procedure is covered in accordance with rule 5160-1-60.4 of the Administrative Code.

(2) Payment for evaluation and management (E&M) services is limited to the following services:

(a) Professional services of the following types necessitating straightforward medical decision-making or medical decision-making of low, moderate, or high complexity:

(i) Office or other outpatient visit;

(ii) Hospital inpatient services;

(iii) Office or outpatient consultations;

(iv) Inpatient consultations;

(v) Nursing facility services;

(vi) Domiciliary, rest home (e.g., boarding home), or custodial care services;

(vii) Home services; and

(b) Hospital discharge services, thirty minutes or less.

(3) Payment for the debridement of nails is limited to one treatment per sixty-day period.

(4) Payment may be made for the following services only if an individual has a localized infection; is under the care of another healthcare practitioner for a metabolic disease such as diabetes mellitus or another condition that may result in circulatory impairment or desensitization in the legs or feet; or has a systemic metabolic, neurologic, or peripheral vascular disease or condition that may require scrupulous foot care by another healthcare practitioner:

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

(b) Cutting or removal of corns and calluses;

(c) Trimming, cutting, or clipping of nails not associated with nail surgery;

(d) Foot care provided for hygienic purposes; and

(e) Treatment of uncomplicated, chronic foot conditions such as flat feet or a subluxated structure in the foot.

(5) Payment may be made for the treatment of mycotic toenails only if the healthcare practitioner attending the mycotic condition furnishes the podiatric physician with clinical evidence of at least one of the following conditions:

(a) Onychomycosis of the toenail; and

(b) Mycosis or dystrophy of the toenail causing secondary infection or pain that has resulted or could result in marked limitation of ambulation.

(6) Payment may be made for the following radiology services as podiatric medicine services only if the indicated criterion is fully documented:

(a) A bilateral radiograph for a unilateral condition or surgical procedure when it is medically indicated;

(b) Radiographs in excess of three views when trauma or infection is present;

(c) A radiograph of soft tissue when infection is present; and

(d) A postoperative radiograph when bone involvement necessitated the surgical procedure or postoperative infection is suspected.

(7) Payment for physical medicine services is limited to acute conditions. When a disease or condition has reached a chronic stage, payment may be made only for services or procedures performed during periods of acute exacerbation.

(8) Payment may be made for a range-of-motion study separately from an examination of the foot only if the need is substantiated by a complete report.

(9) Payment may be made for vaccinations administered within a podiatrist's normal scope of practice in accordance with state law and rule 5160-4-12 of the Administrative Code.

(10) The following services are not covered as podiatric medicine services:

(a) Vitamin B-12 injection for strengthening tendons, ligaments, or other components of the foot;

(b) Medical supplies and equipment (e.g., tape, dressing, surgical trays) that are provided during a podiatric medicine visit and are not intended for take-home use; and

(c) The use of radiography or radioactive material for therapeutic purposes.

Last updated April 13, 2021 at 9:48 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.20,5164.02
Five Year Review Date: 4/1/2026
Prior Effective Dates: 12/21/1977, 1/1/2001, 12/29/2006 (Emer.)
Rule 5160-7-02 | Podiatric medicine: scope of coverage.
 

(A) Podiatric physicians may receive medicaid payment for covered services (as defined in Chapter 5160-7 of the Administrative Code) which consist of the medical, mechanical and surgical treatment of ailments of the foot, the muscles and tendons of the leg governing the foot, and superficial lesions of the hand other than those associated with trauma. The podiatric physician may also receive medicaid payment for treatment of the local manifestation of systemic disease as they appear in the hand and foot, but the individual must be concurrently referred to an eligible prescriber for treatment of the systemic disease itself.

(B) Podiatric medicine services provided by non-physicians under the direct and general supervision of a podiatric physician are covered in accordance with rule 5160-4-02 of the Administrative Code.

(C) Hospital-based podiatric physicians and surgeons are covered in accordance with rule 5160-4-01 of the Administrative Code.

(D) Podiatric medicine services provided in a teaching setting are covered as set forth in rule 5160-4-05 of the Administrative Code.

(E) Podiatric medicine services provided in a long-term care setting are covered as detailed in rules 5160-3-19 and 5123:2-7-11 of the Administrative Code.

(F) Podiatric medicine services provided by a physician assistant are covered in accordance with rule 5160-4-03 of the Administrative Code.

(G) By report services are covered in accordance with rule 5160-4-02.1 of the Administrative Code. For these services, a provider must submit a report documenting the following:

(1) Complete description of the services or procedures;

(2) Diagnosis, both preoperative and postoperative;

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

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

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

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

(7) Operative time.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.20, 5164.02
Five Year Review Date: 12/1/2021
Prior Effective Dates: 9/1/1989
Rule 5160-7-03 | Covered podiatric services and associated limitations.
 

(A) Visit limitations.

(1) Visits are covered in accordance with rules 5160-3-19, 5123:2-7-11 and 5160-4-06 of the Administrative Code.

(2) Payment for evaluation and management services shall be limited to the following services:

(a) Office or other outpatient visit, requiring medical decision making of straightforward, low, moderate or high complexity;

(b) Hospital inpatient services, requiring medical decision making of straightforward, low, moderate or high complexity;

(c) Hospital discharge services, thirty minutes or less;

(d) Office or outpatient consultations, requiring medical decision making of straightforward, low, moderate or high complexity;

(e) Inpatient consultations, requiring medical decision making of straightforward, low, moderate or high complexity;

(f) Nursing facility services, initial or subsequent care, requiring medical decision making of straightforward, low, moderate or high complexity;

(g) Domiciliary, rest home (eg. boarding home) or custodial care services, requiring medical decision making of straightforward, low, moderate or high complexity; and

(h) Home services, requiring medical decision making of straightforward, low, moderate or high complexity.

(B) Therapeutic injections and prescribed drugs are covered in accordance with rule 5160-4-12 of the Administrative Code. In addition, vitamin B-12 injections for strengthening tendons, ligaments, or other components of the foot are not covered.

(C) Surgeries.

(1) Surgeries are covered in accordance with rules 5160-4-22 and 5160-4-23 of the Administrative Code.

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

(D) Laboratory services are covered in accordance with Chapters 5160-4, 5160-3, 5160-11 and 5123:2-7 of the Administrative Code.

(E) Radiology services.

(1) Radiology services are covered in accordance with Chapters 5160-4 and 5160-11 of the Administrative Code.

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

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

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

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

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

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

(F) Physical medicine services.

(1) Physical medicine services are covered in accordance with Chapter 5160-8 of the Administrative Code.

(2) In addition, the following limitations apply:

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

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

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

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

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

(3) The scope and extent of coverage for medical supplies and durable medical equipment, including orthopedic shoes and foot orthoses, are covered in Chapters 5160-4 and 5160-10 of the Administrative Code.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.20, 5164.02
Five Year Review Date: 12/1/2021
Prior Effective Dates: 5/9/1986, 7/1/1992, 1/1/2001
Rule 5160-7-04 | Podiatric medicine: noncovered services.
 

(A) The following services are noncovered:

(1) All services exceeding the policies and limitations defined in Chapters 5160-4 and 5160-7 of the Administrative Code.

(2) Services determined by the department as not medically necessary as defined in Chapter 5160-1 of the Administrative Code.

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

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

(2) Cutting or removal of corns and calluses;

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

(4) Foot care provided for hygienic services;

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

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

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

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

Supplemental Information

Authorized By: 5164.02
Amplifies: 5162.20, 5164.02
Five Year Review Date: 12/1/2021
Prior Effective Dates: 4/7/1977, 1/1/2001