Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-8 - Therapeutic and Diagnostic Services
Section 5160-8-32 - Skilled therapy: coverage
Universal Citation: OH Admin Code 5160-8-32
Current through all regulations passed and filed through September 16, 2024
(A) Payment may be made for a skilled therapy service if the following conditions are met:
(1)
The service is
medically necessary, in accordance with rule
5160-1-01 of the Administrative
Code.
(2)
The service is rendered on the basis of a clinical
evaluation and assessment and in accordance with a treatment plan. (Audiology
must meet this condition in order to be considered skilled therapy for purposes
of this chapter.) The performance of a clinical evaluation and assessment and
the development of a treatment plan are discrete services; payment for them is
made separately from payment for skilled therapy. The clinical evaluation and
assessment and the treatment plan are described in rule
5160-8-33 of the Administrative
Code; copies must be kept on file by the provider.
(3)
The amount,
frequency, and duration of treatment is reasonable. For rehabilitative
services, the maximum treatment period without reevaluation is sixty days; for
developmental services, the maximum treatment period without reevaluation is
six months.
(B) The following limitations and additional requirements are placed on the provision of skilled therapy services:
(1)
For dates of
service January 1, 2014, and after, payment for skilled therapy services
rendered without prior authorization in a non-institutional setting is subject
to the following limits:
(a)
For physical therapy services, a total of no more than
thirty visits per benefit year;
(b)
For occupational
therapy services, a total of no more than thirty visits per benefit year;
and
(c)
For speech-language pathology and audiology services,
a total of no more than thirty visits per benefit year.
(2)
Payment for additional skilled therapy visits in a non-institutional setting
can be requested through the prior authorization process, which is described in
Chapter 5160-1 of the Administrative Code.
(3)
For each type of
skilled therapy, payment for evaluation services can be made not more than once
per injury or condition.
(4)
For each type of skilled therapy, payment for
reevaluation of rehabilitative services cannot be made more often than once
every sixty days.
(5)
For each type of skilled therapy, payment for
reevaluation of developmental services cannot be made more often than once
every six months.
(6)
No payment is made for the following services as
skilled therapy:
(a)
Services reported on a claim submitted by an entity
that neither is nor acts on behalf of an eligible provider of skilled therapy
services;
(b)
Services not rendered by nor under the supervision of
a physician or skilled therapist;
(c)
Services that do
not meet current accepted standards of practice;
(d)
Services
rendered in a non-approved location;
(e)
Additional
rehabilitative services for a patient who fails to demonstrate progress within
a sixty-day treatment period;
(f)
Additional
developmental services for a patient who fails to demonstrate progress within a
six-month treatment period;
(g)
Consultations
with family members or other non-medical personnel; and
(h)
Services
rendered in non-institutional settings and listed as non-covered in rule
5160-4-28 or in appendix DD to
rule 5160-1-60 of the Administrative
Code.
Replaces: Part of 5160-34- 01.2
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