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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-8. Limited Practitioner Services |
5160-8-32. Skilled therapy: coverage [RESCINDED]
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(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.