Rule 5160-8-51 | Acupuncture services.
(A) Definitions.
(1) "Acupuncture" has the same meaning as in Chapter 4762. of the Revised Code.
(2) "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.
(B) Providers.
(1) Rendering provider. The following eligible providers may render a covered acupuncture service:
(a) An acupuncturist recognized under section 4762.02 of the Revised Code; or
(b) An individual practitioner, other than an acupuncturist, who may render acupuncture services by virtue of holding a credential specified by law (e.g., a physician or a chiropractor).
(2) Billing ("pay-to") provider. The following eligible providers may receive medicaid payment for submitting a claim for a covered acupuncture service:
(a) An acupuncturist recognized under section 4762.02 of the Revised Code;
(b) An individual practitioner, other than an acupuncturist, who may render acupuncture services by virtue of holding a credential specified by law;
(c) An outpatient rehabilitation clinic, primary care clinic, or public health department clinic that meets the criteria set forth in Chapter 5160-13 of the Administrative Code;
(d) A federally qualified health center (FQHC);
(e) A rural health clinic (RHC);
(f) An individual practitioner who supervises an acupuncturist or other credentialed acupuncture provider;
(g) A professional medical group; or
(h) A hospital.
(C) Coverage.
(1) Payment may be made only for an acupuncture service that meets the following criteria:
(a) It is medically necessary in accordance with rule 5160-1-01 of the Administrative Code;
(b) It is performed in accordance with section 4762.10 or 4762.11 of the Revised Code; and
(c) It is rendered for treatment only of the following conditions:
(i) Low back pain;
(ii) Migraine;
(iii) Cervical (neck) pain;
(iv) Osteoarthritis of the hip;
(v) Osteoarthritis of the knee;
(vi) Nausea or vomiting related to pregnancy or chemotherapy; or
(vii) Acute post-operative pain.
(2) Payment for more than thirty acupuncture visits per benefit year is subject to prior authorization.
(3) No separate payment is made for both an evaluation and management service for any of the conditions listed in this rule and an acupuncture service rendered by the same provider to the same individual on the same day.
(4) No separate payment is made for services that are an incidental part of a visit (e.g., providing instruction on breathing techniques, diet, or exercise).
(5) No separate payment is made to a non-physician acupuncture provider who performs an acupuncture service in a hospital setting. Instead, the provider makes payment arrangements directly with the participating hospital.
(6) No payment will be made for additional treatment in either of the following circumstances:
(a) Symptoms show no evidence of clinical improvement after an initial treatment period; or
(b) Symptoms worsen over a course of treatment.
(D) Claim payment.
(1) For a covered acupuncture service rendered at an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.
(2) For a covered acupuncture service rendered at any other valid place of service, payment is the lesser of the provider's submitted charge or the maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.
Last updated April 8, 2021 at 1:29 PM
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