Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-12 - Immunizations, injections and infusions (including trigger - point injections), skin substitutes, and provider-administered pharmaceuticals

(1) A "not otherwise specified," "unlisted," or "miscellaneous" procedure code should be reported on a claim only if no procedure code is available that identifies the particular service or item provided.

(2) No separate payment is made for an immunization, injection, infusion, vaccine, toxoid, or provider-administered pharmaceutical as a medical service if it is provided in a hospital setting (inpatient hospital, outpatient hospital, or hospital emergency department).

(3) A provider-administered pharmaceutical reported on a claim submitted in accordance with Chapter 5160-9 of the Administrative Code is regarded as a pharmacy service rather than a professional medical service, and payment of the claim is governed by the provisions of that chapter. For example, a vaccine, toxoid, or other provider-administered pharmaceutical prescribed for a resident of a long-term care facility (LTCF) and subsequently administered by a LTCF staff member is a pharmacy service.

(4) Payment for an immunization, injection, or infusion includes related supplies (e.g., alcohol wipes, needles, syringes, and tubing).

(1) Payment for administration may take one of two forms:

(2) Separate payment may be made for the vaccine or toxoid. No payment, however, will be made for vaccines that can be obtained at no cost through the federal vaccines for children (VFC) program, which is administered by the Ohio department of health (ODH).

(3) Limitations apply to certain vaccines.

(1) An injection or infusion has two components: the administration of a fluid medium and, except in the case of hydration, the pharmaceutical itself. No separate payment is made for the administration service if an injection or infusion is given during the course of an office visit or in conjunction with another medical service that includes an evaluation and management element.

(2) Payment may be made for an injection or infusion or a provider-administered pharmaceutical only if at least one of the following criteria is met:

(3) No separate payment is made for an injection or infusion or a provider-administered pharmaceutical that meets either of the following criteria:

(4) Immune globulin is covered when it is used to provide passive immunity to an individual who is immunosuppressed; has an acquired or congenital immunodeficiency; is at risk of Rh-isoimmunization; or is in immediate danger of contracting a communicable disease through direct contact with blood, saliva, or other body fluids through an open wound, bite, puncture, or mucous membrane.

(5) Epoetin alfa (EPO) for the treatment of anemia, either associated with or not related to chronic renal failure, is covered as a medical service when a provider incurs the cost of the drug and the service is provided in a dialysis center or office setting.

(6) Certain procedure codes represent a specific number of dosage units. On a claim, the fewest number of procedure codes are to be reported together to represent the administered dosage.

(1) A trigger point is a hyperexcitable area of the body, where the application of a stimulus will provoke pain to a greater degree than in the surrounding area. The purpose of a trigger-point injection is to treat not only the symptom but also the cause through the injection of a single substance (e.g., a local anesthetic) or a mixture of substances (e.g., a corticosteroid with a local anesthetic) directly into the affected body part in order to alleviate inflammation and pain. Payment may be made for a trigger-point injection only if the following criteria are met:

(2) A trigger-point injection is normally considered to be a stand-alone service. No additional payment will be made for an office visit on the same date of service unless there is an indication on the claim (e.g., in the form of a modifier appended to the evaluation and management procedure code) that a separate evaluation and management service was performed.

(3) Certain trigger-point injection procedure codes specify the number of injection sites. For these codes, the unit of service is different from the number of injections given. Payment may be made for one unit of service of the appropriate procedure code reported on a claim for service rendered to a particular patient on a particular date.

(4) Trigger-point injections should be repeated only if doing so is reasonable and medically necessary. For trigger-point injections of a local anesthetic or a steroid, payment will be made for no more than eight dates of service per calendar year per patient.

(1) Skin substitutes may be used on burns or ulcers when grafting with actual skin is not an appropriate option. Skin substitutes are expected to function as a permanent replacement for lost or damaged skin. They may be used for temporary wound coverage or wound closure as appropriate and medically necessary. Payment may be made for a skin substitute if a practitioner determines that the skin substitute will be of benefit for the particular type of wound.

(2) The results of treatment are to be documented in the individual's medical record. Payment will not be made for additional applications or re-applications if the wound volume has not decreased by at least fifty per cent after three separate treatments over twelve weeks.

(1) On the department's web site, http://medicaid.ohio.gov, is a list of vaccines, toxoids, skin substitutes, and other provider-administered pharmaceuticals each of which is covered by medicaid either as a medical service or as a VFC-designated vaccine. Payment for a covered non-VFC vaccine, toxoid, skin substitute, or other provider-administered pharmaceutical is the lesser of the provider's submitted charge or the first applicable item from the following ordered list:

(2) Payment for any other covered administration service or evaluation and management service listed in appendix DD to rule 5160-1-60 of the Administrative Code is made in accordance with that rule.