Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-4 - Physician Services
Section 5160-4-25 - Radiology and imaging services performed by a practitioner
Universal Citation: OH Admin Code 5160-4-25
Current through all regulations passed and filed through September 16, 2024
(A) Coverage.
(1) Total (global) procedure. Payment may be
made to a practitioner for performing both the professional and technical
components of a radiology or imaging procedure if two conditions are met:
(a) The technical component was not performed
in a hospital setting (i.e., an inpatient hospital, an outpatient hospital, or
a hospital emergency department); and
(b) The practitioner who submitted the claim
either performed the professional component or has an employment or written
contractual arrangement with the practitioner who performed the professional
component.
(2) Technical
component. Payment may be made to a practitioner for performing only the
technical component of a radiology or imaging procedure if three conditions are
met:
(a) The professional component was
performed by another practitioner;
(b) The technical component was not performed
in a hospital setting; and
(c) The
practitioner who submitted the claim either performed the technical component
or employs the practitioner who performed the technical component.
(3) Professional component.
(a) Payment may be made to a practitioner for
performing only the professional component of a radiology or imaging procedure
if the professional component represents either of two services:
(i) The initial interpretation of
the result of a radiology or imaging procedure;
or
(ii) The interpretation by a
specialist of the result of a radiology or
imaging procedure that has already been interpreted by another practitioner
(e.g., a treating physician).
(b) No payment is made for the interpretation
by a non-specialist of the result of a radiology
or imaging procedure that has already been interpreted by a
specialist.
(4)
Mammography services.
(a) Payment for
screening mammography may be made at the following frequencies:
(i) For an individual who is at least
thirty-five years of age but less than forty, once; and
(ii) For an individual who is at least forty
years of age, once per twelve months.
(b) Payment for diagnostic mammography may be
made for an individual, regardless of age, who shows clinical symptoms of
breast cancer or who is at high risk for developing breast cancer.
(5) No separate payment is made
for supplies used in connection with a radiology or imaging procedure performed
in a hospital setting.
(6) No
separate payment is made for conscious sedation administered in connection with
a radiology or imaging procedure.
(B) Claim payment.
(1) For a covered radiology or imaging
procedure or radiology or imaging procedure component performed by a
non-hospital provider, payment is the lesser of the submitted charge or the
product of the following two figures:
(a) The
maximum payment amount listed in appendix DD to rule
5160-1-60 of the Administrative
Code; and
(b) The relevant
percentage indicated by the 'prof/tech split' entry listed in appendix DD to
rule 5160-1-60 of the Administrative Code (or one
hundred per cent if no entry is listed).
(2) If more than one advanced imaging
procedure (e.g., computed tomography, magnetic resonance imaging, ultrasound)
is performed by the same provider or provider group for an individual patient
in the same session, then the procedure 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. The payment amount for a
covered advanced imaging procedure is the lesser of the 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 a primary procedure, it is one
hundred per cent.
(b) For each
additional total procedure, it is fifty per cent.
(c) For the technical component alone of each
additional procedure, it is fifty per cent.
(d) For the professional component alone of
each additional procedure, it is ninety-five per cent.
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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