Chapter 5160-8 | Therapeutic and Diagnostic Services

Rule 5160-8-05 | Behavioral health services-other licensed professionals.

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

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

(1) Provisions governing payment for behavioral 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.

(2) For services provided in a nursing facility, the cost for behavioral health services are paid directly to the provider of services and not through the nursing facility per diem rate.

(B) Definitions for the purposes of this rule.

(1) "Behavioral health service" is a service or procedure that is performed for the diagnosis and treatment of mental, behavioral, substance use, 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) Licensed independent social worker, section 4757.27;

(c) Licensed independent marriage and family therapist, section 4757.30;

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

(e) School psychologist licensed by the state board of psychology has the same meaning as in rule 4732-3-01 of the Administrative Code and who is engaged in the "practice of school psychology" as that term is defined in section 4732.01 of the Revised Code.

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

(a) Licensed professional counselor, section 4757.23;

(b) Licensed social worker, section 4757.28;

(c) Licensed marriage and family therapist, section 4757.30;

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

(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 who can operate under the general or direct supervision of a licensed practitioner:

(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) Any individual registered with the Ohio board of psychology in compliance with requirements in rule 4732-13-04 of the Administrative Code, working under the supervision of a licensed psychologist, and assigned by the supervising psychologist a title appearing in rule 4732-13-03 of the Administrative Code, such as "assistant," "psychology assistant," "psychology intern," "psychology fellow," or "psychology resident."

(6) "General supervision" is defined as the supervising practitioner being available by phone to provide assistance as needed.

(7) "Direct supervision" is defined as the supervising practitioner being immediately available and interruptible to provide assistance as needed.

(8) "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 licensed independent practitioner must be enrolled in the medicaid program as an eligible provider, even if services are rendered under the supervision of another 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 behavioral health services:

(a) Psychiatric diagnostic evaluation;

(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;

(d) Therapeutic services:

(i) Individual psychotherapy:

(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);

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

(a) Family psychotherapy without patient present; and

(b) Family psychotherapy with patient present;

(iii) Group psychotherapy:

(a) Group psychotherapy; and

(b) Multiple-family group psychotherapy;

(iv) Interactive complexity

(v) Prolonged service

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

(a) To a physician, group practice, clinic, or a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code, for a behavioral health service rendered by a licensed psychologist, or independent practitioner, employed by or under contract with the physician group practice, clinic or community behavioral health center;

(b) To a physician group practice, clinic, a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code, physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice or independent practitioner in independent practice for a behavioral health service rendered by a supervised practitioner or supervised trainee under general supervision of the supervising practitioner who was, at a minimum, available by phone to provide assistance as needed.

(c) To a physician group practice, clinic, a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code, physician, advanced practice registered nurse, physician assistant, licensed psychologist in independent practice or independent practitioner in independent practice for a behavioral health service rendered by a supervised trainee under direct supervision if the following conditions are met:

(i) The professional responsible for the patient's care has contact with the patient during the initial visit and contact not less often than once per quarter (or during each visit if visits are scheduled more than three months apart).

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

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

(3) The following coverage limits, which may be exceeded only with prior authorization from the ODM designated entity, are established for behavioral health services provided to a medicaid recipient.

(a) For diagnostic evaluation, one encounter, per code, per billing provider, per recipient, per calendar year, not on the same date of service as a therapeutic visit;

(b) For psychological testing a maximum of twelve hours per recipient, per calendar year; and

(c) For neuropsychological testing, a maximum of eight hours per recipient, per calendar year;

(d) For screening, brief intervention and referral to treatment for substance use disorder, one of each code, per billing provider, per recipient, per calendar year.

(E) Constraints.

(1) Every behavioral health service reported on a claim must be within the scope of practice of the licensed professional, with appropriate certification 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) No payment will be made under this rule for the following activities:

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

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

(c) Services that are unrelated to the treatment of a specific behavioral health diagnosis 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);

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

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

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

(F) Documentation of services.

(1) The patient's medical record 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 recorded it.

(a) All relevant diagnoses pertaining to medical or physical conditions as well as to behavioral health;

(b) A treatment plan which must be completed within five sessions or one month of admission, whichever is longer and must specify mutually agreed upon treatment goals, track responses to ongoing treatment, and present a prognosis that documents that the plan has been reviewed with the patient and, as appropriate, with family members, parents, legal guardians or custodians or significant others;.

(c) The inability or refusal of the patient to participate in treatment planning or services must be documented and the reason given.

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

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

(f) Discharge summaries which include date of admission, date of last service, outcome of the service and recommendations and referrals made to the patient.

(2) The following items must be included as progress note documentation and shall be completed at a minimum on a per provision basis, or on a daily or weekly basis:

(a) The type, description, date, time of day, duration, location and, if documenting weekly services, the frequency of treatment, with dates of service;

(b) A description of the patient's current symptoms and changes in functional impairment;

(c) Changes in medications taken by or prescribed for the patient when applicable;

(d) The amount of time spent by the provider with the patient;

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

(f) Progress notes shall include assessment of the patient's progress or lack of progress and a brief description of the progress made, if any, significant changes in symptoms, functioning, or events in the life of the patient and recommendation for modifications to the treatment plan, if applicable; and

(g) Evidence of clinical supervision, as required.

(G) Claim payment.

The payment amount for a behavioral health service rendered by a community behavioral health center that meets the requirements found in rule 5160-27-01 of the Administrative Code is the lesser of the provider's submitted charge or the amount specified in rule 5160-27-03 of the Administrative Code. For all other providers of behavioral health services, the payment amount is the lesser of the provider's submitted charge or the applicable percentage of the amount specified in the appendix to rule 5160-1-60 of the Administrative Code:

(1) For testing, one hundred per cent;

(2) For a behavioral 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.

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

(c) For a service rendered by a supervised trainee/assistant under direct supervision, the rate of their supervising practitioner.

(d) For a service rendered by a supervised trainee/assistant under general supervision, it is eighty-five per cent of the rate of their supervising practitioner.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02 , 5164.03
Five Year Review Date: 12/27/2023
Prior Effective Dates: 8/17/2003, 1/1/2008, 12/31/2012 (Emer.), 3/28/2013

Rule 5160-8-11 | Chiropractic services.

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

(A) Scope. This rule sets forth provisions governing payment for professional, non-institutional spinal manipulation and related diagnostic imaging services.

(B) Providers.

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

(a) A chiropractor, defined in Chapter 4734. of the Revised Code.

(b) A mechanotherapist, defined in Chapter 4731. of the Revised Code.

(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;

(e) A nursing facility, rules for which are set forth in Chapter 5160-3 of the Administrative Code;

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

(g) A federally qualified health center (FQHC), rules for which are set forth in Chapter 5160-28 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 is to be determined either by diagnostic imaging or by physical examination confirming that the following criteria are 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.

(c) Acupuncture services in accordance with rule 5160-8-51 of the Administrative Code.

(d) Evaluation and management services.

(i) Office or other outpatient visit for the evaluation and management of a new patient, involving either straightforward medical decision-making or a total time of from fifteen to twenty-nine minutes.

(ii) Office or other outpatient visit for the evaluation and management of a new patient, involving either low-level medical decision-making or a total time of from thirty to forty-four minutes.

(iii) Office or other outpatient visit for the evaluation and management of an established patient, for which the presence of a physician or other qualified healthcare professional may not be needed.

(iv) Office or other outpatient visit for the evaluation and management of an established patient, involving either straightforward medical decision-making or a total time of from ten to nineteen minutes.

(v) Office or other outpatient visit for the evaluation and management of an established patient, involving either low-level medical-decision making or a total time of from twenty to twenty-nine minutes.

(3) For a covered chiropractic service rendered at an FQHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(D) Constraints and limitations.

(1) The following coverage limits 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;

(d) Evaluation and management, four sessions per benefit year; and

(e) 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 not chiropractic manipulation, diagnostic imaging to determine the existence of a subluxation, or evaluation and management, illustrated by the following examples:

(i) Diagnostic studies;

(ii) Drugs;

(iii) Equipment used for manipulation;

(iv) Injections;

(v) Laboratory tests;

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

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

(viii) Orthopedic devices;

(ix) Physical therapy;

(x) Supplies; and

(xi) Traction.

Last updated November 1, 2022 at 8:50 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 5/1/2026
Prior Effective Dates: 2/10/1986, 12/31/1986 (Emer.), 3/22/1997, 7/1/2002, 5/8/2016

Rule 5160-8-35 | Skilled therapy services.

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

(A) Scope. This rule sets forth provisions governing payment for skilled therapies as non-institutional professional services furnished by skilled therapists and skilled therapist assistants or aides. 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) Physical medicine services furnished by or under the supervision of a physician, advanced practice registered nurse, or physician assistant, Chapter 5160-4;

(4) Physical medicine services furnished by or under the supervision of a podiatrist, Chapter 5160-7;

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

(6) Services rendered by the following providers:

(a) Ambulatory health care clinics, Chapter 5160-13; or

(b) Federally qualified health centers (FQHCs) or rural health clinics (RHCs), Chapter 5160-28;

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

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

(B) Definitions.

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

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

(5) "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.

(6) "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.

(7) "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.

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

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

(10) "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.

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

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

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

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

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

(16) "Speech-language pathology" and "audiology" have the same meaning as in section 4753.01 of the Revised Code.

(17) "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.

(18) "Treatment" is a collective term encompassing two types of skilled therapy service:

(a) "Developmental service" is a skilled therapy service 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.

(b) "Rehabilitative service" is a skilled therapy service rendered to individuals for the purpose of improving functionality.

(C) Providers.

(1) Rendering providers. The following practitioners may render a skilled therapy service in the applicable discipline, within their scope of practice, and in accordance with any requirements established by their credentialing board:

(a) A skilled therapist or mechanotherapist;

(b) A licensed physical therapist assistant, occupational therapy assistant, speech-language pathology aide, or audiology aide who provides a particular service to one individual at a time under supervision;

(c) A physical therapy student, occupational therapy student, speech-language pathology student, or audiology student who is completing an internship or externship in accordance with the clinical requirements of the specific discipline as established by the credentialing board; or

(d) A person holding a conditional license to practice speech-language pathology, if the eligible provider supervising the professional experience fulfills all applicable requirements for documentation.

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

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

(i) A hospital;

(ii) A physician, advanced practice registered nurse, physician assistant, or podiatrist;

(iii) A professional medical group;

(iv) An ambulatory health care clinic; or

(v) An FQHC or RHC.

(b) 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:

(i) A skilled therapist; or

(ii) A mechanotherapist.

(D) Coverage.

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

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

(b) The amount, frequency, and duration of service is reasonable. For rehabilitative services, reevaluation may be performed not more frequently than every thirty days nor less frequently than every sixty days; for developmental services, reevaluation may be performed not more frequently than every thirty days nor less frequently than every six months.

(c) The service is rendered on the basis of a clinical evaluation and assessment and in accordance with a treatment or maintenance plan. The performance of a clinical evaluation and assessment and the development of a treatment or maintenance plan are discrete services; payment for them is made separately from payment for skilled therapy. Copies of the clinical evaluation and assessment and the treatment or maintenance plan are to be kept on file by the provider.

(d) The service is rendered in response either to a prescription (in the case of physical therapy or occupational therapy) or to a referral (in the case of speech-language pathology and audiology) issued by a licensed practitioner of the healing arts, in accordance with 42 C.F.R. 440.110 (October 1, 2017) and rule 5160-1-17.9 of the Administrative Code. This condition does not apply to services rendered through the medicaid school program, which is described in Chapter 5160-35 of the Administrative Code.

(2) 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 not more than thirty visits per benefit year;

(b) For occupational therapy services, a total of not more than thirty visits per benefit year; and

(c) For speech-language pathology and audiology services, a total of not more than thirty visits per benefit year.

(3) Payment for additional skilled therapy visits in a non-institutional setting can be requested through the prior authorization process, which is described in rule 5160-1-31 of the Administrative Code.

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

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

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

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

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

(c) Services that are rendered in non-institutional settings but are listed in rule 5160-1-61 of the Administrative Code as being excluded from coverage.

(E) Clinical documentation.

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

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

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

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

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

(e) Other test results and interpretation;

(f) 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:

(i) 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

(ii) 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

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

(2) 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:

(a) The patient's relevant medical history;

(b) 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;

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

(d) The date of each skilled therapy service;

(e) The signature of the practitioner responsible for the treatment or maintenance plan;

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

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

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

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

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

(ii) The development of a new or revised maintenance plan; or

(iii) The discontinuation of therapy.

(F) Claim payment.

(1) 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 an individual 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 to be the primary procedure. Payment for a covered 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:

(a) For the first unit of a primary procedure, one hundred per cent; or

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

(2) Payment will be made only for covered services that are listed in the treatment or maintenance plan.

Last updated January 2, 2024 at 8:46 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02, 5164.06
Five Year Review Date: 1/1/2029
Prior Effective Dates: 1/1/2008, 7/31/2009 (Emer.), 6/12/2020 (Emer.)

Rule 5160-8-41 | Services provided by a dietitian.

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

(A) Providers.

(1) Rendering providers. The following practitioners, defined in Chapter 4759. of the Revised Code, may enroll in medicaid as eligible providers of dietitian services:

(a) A licensed dietitian; and

(b) A registered dietitian.

(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) An independent licensed dietitian;

(b) An independent registered dietitian;

(c) A professional medical group;

(d) An ambulatory health care clinic; or

(e) A federally qualified health center (FQHC) or rural health clinic (RHC).

(B) Coverage. Payment may be made for the following services provided by a dietitian:

(1) Medical nutrition therapy services specified in "Current Procedural Terminology," published by the American medical association (AMA), http://www.ama-assn.org;

(2) Lactation consultation services; and

(3) Diabetes self-management training (DSMT) services, in accordance with rule 5160-8-53 of the Administrative Code.

(C) Claim payment.

(1) Payment for a covered service provided by a dietitian in an FQHC site or RHC site is determined in accordance with Chapter 5160-28 of the Administrative Code.

(2) Payment for a covered service provided by a dietitian in a setting other than an FQHC site or RHC site is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

Last updated October 1, 2024 at 9:23 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/1/2029
Prior Effective Dates: 7/1/2021

Rule 5160-8-42 | Lactation consultation services.

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

(A) Definitions applicable to this rule.

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

(2) "Lactation consultation" is the development and implementation of management strategies for complex problems related to breastfeeding and human lactation.

(3) "International Board-Certified Lactation Consultant (IBCLC)" is a professional member of the healthcare team who has earned and maintains the credential established by the "International Board of Lactation Consultant Examiners," which attests to expertise in breastfeeding management and care, including the insight, skills, and knowledge needed to identify complex breastfeeding problems, to provide education about breastfeeding, and to facilitate an optimal breastfeeding experience and environment.

(B) Providers.

(1) Rendering providers. The following eligible providers may receive medicaid payment for rendering a lactation consultation service:

(a) An IBCLC;

(b) An advanced practice registered nurse;

(c) A physician; or

(d) A physician assistant.

(2) Billing ("pay-to") providers. The following eligible providers may receive medicaid payment for lactation consultation services on behalf of a rendering provider:

(a) The rendering provider;

(b) A professional medical group practice;

(c) A professional dental group practice;

(d) A pharmacy;

(e) A federally qualified health center (FQHC);

(f) A rural health clinic (RHC); or

(g) An ambulatory health care clinic.

(C) Coverage.

(1) Payment for a lactation consultation service is made separately from payment for other professional services. No separate payment, however, is made for a lactation consultation service provided in conjunction with nurse home visiting services (which are addressed in rule 5160-21-05 of the Administrative Code).

(2) For a lactation consultation service, the practitioner order specified in rule 5160-1-17 of the Administrative Code is waived.

(D) Claim payment.

(1) Payment for a covered lactation consultation service provided in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.

(2) Payment for a covered lactation consultation service provided by an FQHC or RHC is made in accordance with Chapter 5160-28 of the Administrative Code.

(3) Payment for a covered lactation consultation service rendered in other settings is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) Payment for lactation pumps and supplies is made in accordance with rule 5160-10-25 of the Administrative Code.

Last updated October 1, 2024 at 9:07 AM

Supplemental Information

Authorized By: 5164.02, 5164.071
Amplifies: 5164.02, 5164.071
Five Year Review Date: 10/1/2029
Prior Effective Dates: 1/1/2022

Rule 5160-8-43 | Doula Services.

• Effective: October 3, 2024
• Promulgated Under: 119.03

(A) Definitions applicable to this rule.

(1) "Doula" is an individual listed in the registry specified in section 4723.89 of the Revised Code.

(2) "Doula service" is any of the support activities specified in section 4723.89 of the Revised Code.

(3) "Independent" and "non-independent," with respect to a doula, have the same meanings as in rule 5160-4-02 of the Administrative Code.

(B) Providers.

(1) Independent doulas may receive medicaid payment for submitting a professional claim for covered services they provide.

(2) The following eligible providers may receive medicaid payment for submitting a professional claim on behalf of a doula, either independent or non-independent, for covered services provided by the doula:

(a) An ambulatory health care clinic;

(b) A federally qualified health center (FQHC);

(c) A freestanding birth center;

(d) A hospital;

(e) A professional medical group; or

(f) A rural health clinic (RHC).

(C) Coverage.

(1) A coverage period is defined by the following beginning and ending dates:

(a) The date of conception, if known, or the date of the first antepartum visit; and

(b) The earlier of the following dates:

(i) Three hundred sixty-five days after delivery; or

(ii) Discontinuation of the individual's medicaid eligibility.

(2) During a coverage period, payment may be made for the following doula services:

(a) One comprehensive support service, regardless of duration, provided during labor and delivery; and

(b) Antepartum and postpartum support services, including consultation and telehealth visits, provided in fifteen-minute units up to a maximum of forty-eight units.

(3) Payment for doula services in excess of these limits may be made through the prior authorization (PA) process described in rule 5160-1-31 of the Administrative Code.

(D) Allowances and constraints.

(1) Separate payment may be made for both an evaluation and management service and a doula service rendered by different providers to the same individual on the same date of service.

(2) There are no place-of-service restrictions for doula services.

(E) Claim payment.

(1) For a covered doula service rendered at an FQHC or RHC, payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(2) For any other covered doula 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 October 3, 2024 at 8:49 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 10/3/2029

Rule 5160-8-51 | Acupuncture services.

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

(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

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 4/1/2026

Rule 5160-8-52 | Services provided by a pharmacist.

• Effective: January 17, 2021
• Promulgated Under: 119.03

(A) Definition. "Pharmacist" has the same meaning as in Chapter 4729:1-1 of the Administrative Code.

(B) Providers. An individual pharmacist may enroll in medicaid as a pharmacist provider.

(C) Coverage.

(1) Payment may be made only for a pharmacist service for which the following criteria are met:

(a) The service is within a pharmacist's scope of practice;

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

(c) For a service rendered by prescription, the pharmacist provider obtains an order issued by a practitioner having appropriate prescriptive authority and maintains supporting documentation; and

(d) The service is rendered for one of the following purposes:

(i) Managing medication therapy under a consulting agreement with a prescribing practitioner pursuant to section 4729.39 of the Revised Code;

(ii) Administering immunizations in accordance with section 4729.41 of the Revised Code; or

(iii) Administering medications in accordance with section 4729.45 of the Revised Code.

(2) Nothing in this rule precludes a medicaid managed care organization described in Chapters 5160-26 and 5160-58 of the Administrative Code from paying pharmacists for additional purposes, within scope of practice, including care management services that are rendered by a pharmacist without a consult agreement.

(3) Payment may be made for covered telehealth services in accordance with rule 5160-1-18 of the Administrative Code.

(4) Services may be rendered through a standing order or protocol as described in Chapter 4729. of the Revised Code.

(D) Claim payment.

(1) For a covered pharmacist service rendered at a federally qualified health center (FQHC) or rural health clinic (RHC), payment as an FQHC medical service or an RHC medical service is made in accordance with Chapter 5160-28 of the Administrative Code.

(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 pharmacist services, payment is the lesser of the submitted charge or eighty-five per cent of the medicaid maximum amount specified in appendix DD to rule 5160-1-60 of the Administrative Code.

(4) No separate payment will be made for pharmacist services provided in an inpatient or outpatient hospital, emergency department, or inpatient psychiatric facility place of service.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 1/17/2021

Rule 5160-8-53 | Diabetes prevention and self-management training.

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

(A) Definitions. For the purposes of this rule, the following definitions apply:

(1) "Diabetes self-management training" (DSMT) is the education and instruction of an individual with diabetes by a qualified provider for the purpose of providing the individual with necessary skills and knowledge to participate in the management of the individual's diabetes, including the self-administration of injectable drugs.

(2) "National Diabetes Prevention Program" (NDPP) is an evidence-based, educational and support program administered by the centers for disease control and prevention (CDC) designed to assist at-risk individuals from developing type 2 diabetes.

(B) DSMT.

(1) Providers.

(a) Rendering providers. The following providers may render or supervise a DSMT service:

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(iv) A registered nurse;

(v) A registered dietitian nutritionist; or

(vi) A pharmacist.

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

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(iv) A licensed or registered dietitian;

(v) A pharmacist;

(vi) A professional medical group;

(vii) A federally qualified health center;

(viii) A rural health clinic;

(ix) An ambulatory health care clinic; or

(x) A hospital.

(2) Coverage.

(a) Payment for diabetes self-management training can be made when the following criteria are met:

(i) The individual has a current diagnosis of diabetes.

(ii) The individual has not previously received diabetes self-management training.

(iii) Training is provided in a setting other than an inpatient hospital or an emergency department.

(b) Payment may be made, with prior authorization in accordance with rule 5160-1-31 of the Administrative Code, for follow-up sessions not to exceed a total of two hours of individual training or group training in any combination.

(C) NDPP.

(1) Providers.

(a) Rendering providers. The following providers may render or supervise an NDPP service:

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

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

(i) A physician;

(ii) A physician assistant;

(iii) An advanced practice registered nurse;

(iv) A professional medical group;

(v) A federally qualified health center;

(vi) A rural health clinic; or

(vii) An ambulatory health care clinic;

(2) Coverage.

(a) Payment for an NDPP service can be made when all of the following criteria are met:

(i) The individual is eighteen years or older;

(ii) The individual is overweight;

(iii) The individual is not currently pregnant; and

(iv) The individual does not have a diagnosis of type 1 or type 2 diabetes.

(v) At least one of the following criteria is met:

(a) The individual has been diagnosed with prediabetes;

(b) The individual has a history of gestational diabetes; or

(c) The individual has had a high-risk result on a prediabetes test.

(D) Claim payment.

(1) No payment will be made for a DSMT or NDPP service provided on the same date of service as medical nutrition therapy.

(2) Payment for a covered service performed in a hospital is made in accordance with Chapter 5160-2 of the Administrative Code.

(3) Payment for a covered service rendered by a federally qualified health center (FQHC) or rural health clinic (RHC) is made in accordance with Chapter 5160-28 of the Administrative Code.

(4) Payment for a covered service rendered in any other setting is the lesser of the submitted charge or the amount shown in appendix DD to rule 5160-1-60 of the Administrative Code.

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