5160-7-03. Covered podiatric services and associated limitations

(A) Visit limitations.

(1) Visits are covered in accordance with rules 5160-3-19, 5123:2-7-11 and 5160-4-06 of the Administrative Code.

(2) Payment for evaluation and management services shall be limited to the following services:

(a) Office or other outpatient visit, requiring medical decision making of straightforward, low, moderate or high complexity;

(b) Hospital inpatient services, requiring medical decision making of straightforward, low, moderate or high complexity;

(c) Hospital discharge services, thirty minutes or less;

(d) Office or outpatient consultations, requiring medical decision making of straightforward, low, moderate or high complexity;

(e) Inpatient consultations, requiring medical decision making of straightforward, low, moderate or high complexity;

(f) Nursing facility services, initial or subsequent care, requiring medical decision making of straightforward, low, moderate or high complexity;

(g) Domiciliary, rest home (eg. boarding home) or custodial care services, requiring medical decision making of straightforward, low, moderate or high complexity; and

(h) Home services, requiring medical decision making of straightforward, low, moderate or high complexity.

(B) Therapeutic injections and prescribed drugs are covered in accordance with rule 5160-4-12 of the Administrative Code. In addition, vitamin B-12 injections for strengthening tendons, ligaments, or other components of the foot are not covered.

(C) Surgeries.

(1) Surgeries are covered in accordance with rules 5160-4-22 and 5160-4-23 of the Administrative Code.

(2) In addition, the following limitation applies: reimbursement for debridement of nails is limited to a maximum of one treatment within a sixty-day period.

(D) Laboratory services are covered in accordance with Chapters 5160-4, 5160-3, 5160-11 and 5123:2-7 of the Administrative Code.

(E) Radiology services.

(1) Radiology services are covered in accordance with Chapters 5160-4 and 5160-11 of the Administrative Code.

(2) In addition, the following radiology services are not covered as podiatric medicine services:

(a) Bilateral x-rays when only a unilateral condition or surgery is reported, unless documented as medically indicated;

(b) X-rays in excess of three views unless the necessity due to trauma or infection is fully documented;

(c) X-rays for soft tissues unless for reasons of infections which is fully documented;

(d) Postoperative x-rays unless there is bone involvement necessitating the surgical procedure or cases of suspected postoperative infections; and

(e) The use of x-rays or radium for therapeutic purposes.

(F) Physical medicine services.

(1) Physical medicine services are covered in accordance with Chapter 5160-8 of the Administrative Code.

(2) In addition, the following limitations apply:

(a) Reimbursement for physical medicine services provided within the scope of practice of podiatric medicine and surgery as specified in the Revised Code is limited to acute conditions only. For those recipients in which the disease has reached a chronic stage, reimbursement will be made only for the periods of acute exacerbation of the disease.

(b) Range of motion studies may not be billed separately from an examination of the foot, unless substantiated by a complete report.

(G) Medical supplies and durable medical equipment (DME).

(1) A podiatric physician may not be separately reimbursed for medical supplies and equipment (e.g., tape, dressing, or surgical trays) utilized in podiatrist's office, clinic, or patient's home during a podiatric visit.

(2) A podiatric physician may be reimbursed for medical supplies and medical equipment dispensed in the podiatric physician's office, clinic or patient's home for use in the patient's home, if the podiatric physician has a "supplies and medical equipment" category of service.

(3) The scope and extent of coverage for medical supplies and durable medical equipment, including orthopedic shoes and foot orthoses, are covered in Chapters 5160-4 and 5160-10 of the Administrative Code.

Effective: 11/1/2017
Five Year Review (FYR) Dates: 03/30/2017 and 12/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.20, 5164.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 5/9/86, 5/19/86, 9/1/89, 2/1/90, 4/1/92 (EMER), 7/1/92, 1/1/01, 8/15/05, 12/29/06 (EMER), 3/29/07, 11/4/10, 12/1/16