Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-06 - Specific provisions for evaluation and management (E&M) services
Universal Citation: OH Admin Code 5160-4-06
Current through all regulations passed and filed through September 16, 2024
(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.
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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