Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-8 - Therapeutic and Diagnostic Services
Section 5160-8-51 - Acupuncture services
Universal Citation: OH Admin Code 5160-8-51
Current through all regulations passed and filed through March 18, 2024
(A) Definitions.
(1)
"Acupuncture" has the same meaning as in Chapter 4762.
of the Revised Code.
(2)
"Eligible provider" has the same meaning as in rule
5160-1-17 of
the Administrative Code.
(B) Providers.
(1)
Rendering
provider. The following eligible providers may render a covered acupuncture
service:
(a)
An
acupuncturist recognized under section
4762.02 of
the Revised Code; or
(b)
An individual practitioner, other than an
acupuncturist, who may render acupuncture services by virtue of holding a
credential specified by law (e.g., a physician or a
chiropractor).
(2)
Billing ("pay-to") provider. The following eligible
providers may receive medicaid payment for submitting a claim for a covered
acupuncture service:
(a)
An acupuncturist recognized under section
4762.02 of
the Revised Code;
(b)
An individual practitioner, other than an
acupuncturist, who may render acupuncture services by virtue of holding a
credential specified by law;
(c)
An outpatient
rehabilitation clinic, primary care clinic, or public health department clinic
that meets the criteria set forth in Chapter 5160-13 of the Administrative
Code;
(d)
A federally qualified health center
(FQHC);
(e)
A rural health clinic (RHC);
(f)
An individual
practitioner who supervises an acupuncturist or other credentialed acupuncture
provider;
(g)
A professional medical group; or
(h)
A
hospital.
(C) Coverage.
(1)
Payment may be
made only for an acupuncture service that meets the following criteria:
(a)
It is medically
necessary in accordance with rule
5160-1-01
of the Administrative Code;
(b)
It is performed
in accordance with section
4762.10
or
4762.11
of the Revised Code; and
(c)
It is rendered for treatment only of the following
conditions:
(i)
Low back pain;
(ii)
Migraine;
(iii)
Cervical (neck)
pain;
(iv)
Osteoarthritis of the hip;
(v)
Osteoarthritis of
the knee;
(vi)
Nausea or vomiting related to pregnancy or
chemotherapy; or
(vii)
Acute post-operative pain.
(2)
Payment for more than thirty acupuncture visits per benefit
year is subject to prior authorization.
(3)
No separate
payment is made for both an evaluation and management service for any of the
conditions listed in this rule and an acupuncture service rendered by the same
provider to the same individual on the same day.
(4)
No separate
payment is made for services that are an incidental part of a visit (e.g.,
providing instruction on breathing techniques, diet, or
exercise).
(5)
No separate payment is made to a non-physician
acupuncture provider who performs an acupuncture service in a hospital setting.
Instead, the provider makes payment arrangements directly with the
participating hospital.
(6)
No payment will be made for additional treatment in
either of the following circumstances:
(a)
Symptoms show no
evidence of clinical improvement after an initial treatment period;
or
(b)
Symptoms worsen over a course of treatment.
(D) Claim payment.
(1)
For a covered
acupuncture service rendered at an FQHC or RHC, payment is made in accordance
with Chapter 5160-28 of the Administrative Code.
(2)
For a covered
acupuncture service rendered at any other valid place of service, payment is
the lesser of the provider's submitted charge or the maximum amount specified
in appendix DD to rule
5160-1-60 of the
Administrative Code.
Replaces: 5160-8-51
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