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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 |
5160-8-51. Acupuncture services
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(A) Unless otherwise noted, any limitations or requirements specified in the Revised Code or in agency 5160 of the Administrative Code apply to services addressed in this rule.
(B) Definitions.
(1) "Acupuncture" has the same meaning as in Chapter 4762. of the Revised Code.
(2) "Acupuncturist" is an individual who holds at least one of the following certificates:
(a) A valid certificate to practice as an acupuncturist issued under Chapter 4762. of the Revised Code; or
(b) A valid certificate to practice as an oriental medicine practitioner issued under Chapter 4762. of the Revised Code.
(3) "Recognized acupuncture provider" is an individual medicaid provider who may receive payment for providing covered acupuncture services, without enrolling separately in medicaid as an acupuncturist, by virtue of holding the credential indicated in the following list:
(a) Chiropractor - a valid certificate to practice acupuncture issued under section 4734.283 of the Revised Code;
(b) Physician - completion of medical training in acupuncture with a current and active designation, or an equivalent designation, as a diplomate in acupuncture from the national certification commission for acupuncture and oriental medicine; or
(c) Other individual medicaid provider (e.g., advanced practice registered nurse, physician assistant) - a valid certificate as an acupuncturist.
(C) Providers. The following eligible providers may receive medicaid payment for submitting a claim for a covered acupuncture service:
(1) An acupuncturist;
(2) A recognized acupuncture provider;
(3) An ambulatory health care clinic as defined in Chapter 5160-13 of the Administrative Code;
(4) A federally qualified health center (FQHC);
(5) A rural health clinic (RHC); or
(6) A professional medical group.
(D) 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 at the written order of a practitioner in accordance with section 4762.10 or 4762.11 of the Revised Code;
(c) It is rendered by a practitioner who is enrolled in the medicaid program; and
(d) It is rendered for treatment only of the following conditions:
(i) Low back pain; or
(ii) Migraine.
(2) Payment for more than thirty acupuncture visits per benefit year requires prior authorization.
(3) No separate payment is made for both an evaluation and management service 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 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.
(E) 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.