Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-14 - Professional services associated with dialysis
Universal Citation: OH Admin Code 5160-4-14
Current through all regulations passed and filed through September 16, 2024
(A) Routine maintenance dialysis.
(1)
Payment for professional services associated with the
medical management of patients receiving maintenance dialysis is made either on
a monthly capitation basis or on a daily basis.
(a)
The monthly
capitation payment is available to a single practitioner in the following
circumstances:
(i)
The practitioner alone provides monthly continuity of
services to a single patient or to a group of patients; or
(ii)
The practitioner
serves as the primary practitioner in a joint provision (in which one person
receives payment on behalf of a team of
practitioners).
(b)
When dialysis care is provided by more than one
practitioner in the absence of a joint provision, payment may be made to each
practitioner separately for the days on which dialysis care was
provided.
(c)
On a submitted claim, the type of service payment
(monthly capitation or daily care) is differentiated by procedure
code.
(2)
In addition to the payment for professional services,
separate payment may be made for the following services:
(a)
The declotting of
shunts; and
(b)
Covered professional services that are unrelated to the
patient's dialysis or renal condition.
(B) Inpatient dialysis services.
(1)
Payment may be made for professional services that are
related to dialysis performed for a hospital inpatient for one of the following
reasons:
(a)
Treatment of acute renal failure or renal
trauma;
(b)
Establishment of an initial course of dialysis (the
first dialysis treatment and all subsequent dialysis treatments performed
before the patient is stabilized on dialysis); or
(c)
Treatment of an
established dialysis patient who was admitted to the hospital for a condition
or illness unrelated to the patient's renal condition.
(2)
The
following provisions apply to payment for professional services related to
inpatient dialysis:
(a)
The time when the practitioner is present with the
patient during the dialysis procedure is documented in the patient's medical
record.
(b)
On a submitted claim, an appropriate procedure code is
used to indicate inpatient dialysis care.
(c)
Payment for
professional services includes all evaluation and management services related
to the patient's renal condition. (The payment to the hospital for inpatient
dialysis includes all other patient care services that are rendered during the
dialysis procedure.)
(d)
If a dialysis patient is admitted to a hospital for no
reason other than to receive maintenance dialysis, the dialysis is considered
to be routine maintenance and payment for professional services is made
accordingly.
(C) For services rendered to a single patient in a single calendar month, the following overpayments or duplicate payments are disallowed:
(1)
More than one
monthly capitation payment;
(2)
Payment for more
than thirty-one days of daily dialysis care; and
(3)
Both the monthly
capitation payment and payment for daily dialysis care.
Replaces: 5160-4-14
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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