Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-13 - Ambulatory Health Care Clinic Services
Section 5160-13-02 - Dialysis services rendered by a dialysis center
Universal Citation: OH Admin Code 5160-13-02
Current through all regulations passed and filed through September 16, 2024
(A) Coverage and limitations.
(1) Payment may be made for dialysis
performed for the treatment of kidney dysfunction resulting from conditions
such as end-stage renal disease (ESRD) or acute kidney injury (AKI).
(2) If an individual is eligible for both
medicare and medicaid, then coverage by medicaid as the primary payer continues
only until medicare coverage begins.
(3) Payment may be made for hemodialysis (HD)
or for any of three types of peritoneal dialysis: intermittent peritoneal
dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), or continuous
cycling peritoneal dialysis (CCPD).
(4)
CAPD or CCPD is
peritoneal dialysis normally performed in a setting other than a dialysis
center.
(5) Dialysis self-care
training is instruction of the individual or a caregiver on how to perform
self-dialysis with little or no professional assistance. It is customarily
provided in conjunction with a session of dialysis treatment.
(6)
The following frequency limits apply:
(a) HD
- one session per day, three
sessions per week;
(b)
IPD, CAPD, or CCPD
- one session per day, seven sessions per
week;
(c) HD self-care training - a
total of twenty-five sessions to be conducted within a period not to exceed
ninety-one days;
(d) IPD self-care
training - a total of twelve sessions to be conducted within a period not to
exceed twenty-eight days; and
(e)
CAPD or CCPD self-care training - a total of fifteen sessions.
(7) Frequency limits
may be exceeded only if the medical necessity of the additional service is
documented in the medical record by the practitioner who is primarily
responsible for the dialysis services.
(B) Payment.
(1) Medicaid payment for a covered dialysis
service rendered by a dialysis center is made as a per-visit payment amount
(PVPA). This medicaid PVPA includes all applicable related services, tests,
equipment, supplies, and incidental instruction furnished on the same date. A
list of these related items, designated by medicare as items that are "subject
to consolidated billing," is published by the centers for medicare and medicaid
services (CMS) in the end-stage renal disease (ESRD) section of its website,
http://www.cms.gov.
(2) PVPAs for covered dialysis services are
listed in the appendix to this rule.
(3) Payment separate from the PVPA may be
made for the following items and services:
(a)
Covered professional dialysis services provided by a medical practitioner,
addressed in rule
5160-4-14 of the Administrative
Code; and
(b) Covered laboratory
services and pharmaceuticals, addressed in Chapter 5160-11 of the
Administrative Code, that are not designated by medicare as "subject to
consolidated billing."
(4) Nothing in this rule precludes a medicaid
managed care organization (described in Chapters 5160-26 and 5160-58 of the
Administrative Code) from paying amounts other than those listed in the
appendix to this rule.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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