(A) Scope. This
rule sets forth provisions governing payment for behavioral health services
provided by certain licensed professionals in non-institutional settings.
(1) Provisions governing payment for
behavioral health services as the following service types are set forth in the
indicated part of the Administrative Code:
(a) Cost-based clinic services, Chapter
5160-28; and
(b) Medicaid school
program services, Chapter 5160-35.
(2) For services provided in a nursing
facility, the cost for behavioral health services are paid directly to the
provider of services and not through the nursing facility per diem
rate.
(B) Definitions for
the purposes of this rule.
(1) "Behavioral
health service" is a service or procedure that is performed for the diagnosis
and treatment of mental, behavioral, substance use, or emotional disorders by a
licensed professional or under the supervision of a licensed professional. As
it is used in this rule, the term includes neither psychiatry nor medication
management.
(2) "Licensed
psychologist" has the same meaning as in section
4732.01 of the Revised Code.
(3) "Independent practitioner" is
a collective term used in this rule to designate the following persons who hold
a valid license to practice in accordance with the indicated portion of the
Revised Code:
(a) Licensed professional
clinical counselor, section
4757.22;
(b) Licensed independent social worker,
section 4757.27;
(c) Licensed independent marriage and family
therapist, section 4757.30;
(d) Licensed independent chemical dependency
counselor, rule
4758-4-01
of the Administrative Code; and
(e)
School psychologist licensed by the state board of psychology has the same
meaning as in rule
4732-3-01 of the
Administrative Code and who is engaged in the "practice of school psychology"
as that term is defined in section
4732.01 of the Revised
Code.
(4) "Supervised
practitioner" is a collective term used in this rule to designate the following
persons who hold a valid license to practice under general supervision in
accordance with the indicated portion of the Revised Code:
(a) Licensed professional counselor, section
4757.23;
(b) Licensed social worker, section
4757.28;
(c) Licensed marriage and family therapist,
section 4757.30;
(d) Licensed chemical dependency counselor
II, rule
4758-4-01
of the Administrative Code; and
(e)
Licensed chemical dependency counselor III, rule
4758-4-01
of the Administrative Code.
(5) "Supervised trainee" is a collective term
used in this rule to designate the following individuals who can operate under
the general or direct supervision of a licensed practitioner:
(a) Registered counselor trainee, defined in
rule
4757-13-09
of the Administrative Code;
(b)
Registered social work trainee, defined in rule
4757-19-05
of the Administrative Code;
(c)
Marriage and family therapist trainee, defined in rule
4757-25-08
of the Administrative Code;
(d)
Chemical dependency counselor assistant, defined in rule
4758-4-01
of the Administrative Code; and
(e)
Any individual registered with the Ohio board of psychology in compliance with
requirements in rule
4732-13-04
of the Administrative Code, working under the supervision of a licensed
psychologist, and assigned by the supervising psychologist a title appearing in
rule
4732-13-03
of the Administrative Code, such as "assistant," "psychology assistant,"
"psychology intern," "psychology fellow," or "psychology
resident."
(6) "General
supervision" is defined as the supervising practitioner being available by
phone to provide assistance as needed.
(7) "Direct supervision" is defined as the
supervising practitioner being immediately available and interruptible to
provide assistance as needed.
(8)
"Independent practice" is a business arrangement in which a professional is not
subject to the administrative and professional control of an employer such as
an institution, physician, or agency. In particular, a professional working
from an office that is located within an entity is considered to be in
independent practice when both of the following conditions are met:
(a) The part of the entity constituting the
office of the professional is used solely for that purpose and is separately
identifiable from the rest of the facility; and
(b) The professional maintains a private
practice (i.e., offers services to the general public as well as to the
customers, residents, or patients of the entity), and the practice is not
owned, either in part or in total, by the entity.
(C) Provider requirements.
(1) A licensed psychologist or licensed
independent practitioner must be enrolled in the medicaid program as an
eligible provider, even if services are rendered under the supervision of
another eligible provider.
(2) A
licensed psychologist in independent practice or independent practitioner in
independent practice who can participate in the medicare program either must do
so or, if the practice is limited to pediatric treatment, must meet all
requirements for medicare participation other than serving medicare
beneficiaries.
(D)
Coverage.
(1) Payment may be made for the
following behavioral health services:
(a)
Psychiatric diagnostic evaluation;
(b) Psychological and neuropsychological
testing;
(c) Assessment and
behavior change intervention:
(i) Alcohol or
substance (other than tobacco) abuse, structured assessment and brief
intervention, fifteen to thirty minutes;
(ii) Alcohol or substance (other than
tobacco) abuse, structured assessment and intervention, greater than thirty
minutes;
(d) Therapeutic
services:
(i) Individual psychotherapy:
(a) Psychotherapy, thirty minutes with
patient and/or family member;
(b)
Psychotherapy, forty-five minutes with patient and/or family member;
(c) Psychotherapy, sixty minutes with patient
and/or family member;
(d)
Psychotherapy for crisis, first sixty minutes;
(e) Psychotherapy for crisis, each additional
thirty minutes; and
(f) Interactive
complexity (reported separately in addition to the primary procedure);
(ii) Family
psychotherapy for which the primary purpose is the treatment of the patient and
not family members:
(a) Family psychotherapy
without patient present; and
(b)
Family psychotherapy with patient present;
(iii) Group psychotherapy:
(a) Group psychotherapy; and
(b) Multiple-family group psychotherapy;
(iv) Interactive
complexity
(v) Prolonged
service
(2)
Payment may be made to the following eligible providers for a behavioral health
service rendered as indicated:
(a) To a
physician, group practice, clinic, or a community behavioral health center that
meets the requirements found in rule
5160-27-01
of the Administrative Code, for a behavioral health service rendered by a
licensed psychologist, or independent practitioner, employed by or under
contract with the physician group practice, clinic or community behavioral
health center;
(b) To a physician
group practice, clinic, a community behavioral health center that meets the
requirements found in rule
5160-27-01
of the Administrative Code, physician, advanced practice registered nurse,
physician assistant, licensed psychologist in independent practice or
independent practitioner in independent practice for a behavioral health
service rendered by a supervised practitioner or supervised trainee under
general supervision of the supervising practitioner who was, at a minimum,
available by phone to provide assistance as needed.
(c) To a physician group practice, clinic, a
community behavioral health center that meets the requirements found in rule
5160-27-01
of the Administrative Code, physician, advanced practice registered nurse,
physician assistant, licensed psychologist in independent practice or
independent practitioner in independent practice for a behavioral health
service rendered by a supervised trainee under direct supervision if the
following conditions are met:
(i) The
professional responsible for the patient's care has in person, face-to-face contact with the patient
during the initial visit and face to face
contact not less often than once per quarter (or during each visit if visits
are scheduled more than three months apart).
(ii) The professional responsible for the
patient's care reviews and updates the patient's medical record at least once
after each treatment visit.
(d) To a physician, advanced practice
registered nurse, physician assistant, licensed psychologist in independent
practice, or independent practitioner in independent practice for a behavioral
health service personally rendered by that health care professional;
(3) The following coverage limits,
which may be exceeded only with prior authorization from the ODM designated
entity, are established for behavioral health services provided to a medicaid
recipient.
(a) For diagnostic evaluation, one
encounter, per code, per billing provider, per recipient, per calendar year,
not on the same date of service as a therapeutic visit;
(b) For psychological testing a maximum of
twelve hours per recipient, per calendar year; and
(c) For neuropsychological testing, a maximum
of eight hours per recipient, per calendar year;
(d) For screening, brief intervention and
referral to treatment for substance use disorder, one of each code, per billing
provider, per recipient, per calendar year.
(E) Constraints.
(1) Every behavioral health service reported
on a claim must be within the scope of practice of the licensed professional,
with appropriate certification and/or training for the service, who renders or
supervises it and must be performed in accordance with any supervision
requirements established in law, regulation, statute, or rule.
(2) No payment will be made under this rule
for the following activities:
(a) Services
that are rendered by an unlicensed individual other than a supervised
trainee;
(b) Activities, testing,
or diagnosis conducted for purposes specifically related to
education;
(c) Services that are
unrelated to the treatment of a specific behavioral health diagnosis but serve
primarily to enhance skills or to provide general information, examples of
which are given in the following non-exhaustive list:
(i) Encounter groups, workshops, marathon
sessions, or retreats;
(ii)
Sensitivity training;
(iii) Sexual
competency training;
(iv)
Recreational therapy (e.g., art, play, dance, music);
(v) Services intended primarily for social
interaction, diversion, or sensory stimulation; and
(vi) The teaching or monitoring of activities
of daily living (such as grooming and personal hygiene);
(d) Psychotherapy services if the patient
cannot establish a relationship with the provider because of a cognitive
deficit;
(e) Family therapy for the
purpose of training family members or caregivers in the management of the
patient; and
(f) Self-administered
or self-scored tests of cognitive function.
(F) Documentation of services.
(1) The patient's medical record must
substantiate the medical necessity of services performed, and each record is
expected to bear the signature and indicate the discipline of the professional
who recorded it.
(a) All relevant diagnoses
pertaining to medical or physical conditions as well as to behavioral
health;
(b) A treatment plan which
must be completed within five sessions or one month of admission, whichever is
longer and must specify mutually agreed upon treatment goals, track responses
to ongoing treatment, and present a prognosis that documents that the plan has
been reviewed with the patient and, as appropriate, with family members,
parents, legal guardians or custodians or significant others;.
(c) The inability or refusal of the patient
to participate in treatment planning or services must be documented and the
reason given.
(d) Test results, if
applicable, with interpretation;
(e) Evidence that the patient has sufficient
cognitive capacity to benefit from treatment; and
(f) Discharge summaries which include date of
admission, date of last service, outcome of the service and recommendations and
referrals made to the patient.
(2) The following items must be included as
progress note documentation and shall be completed at a minimum on a per
provision basis, or on a daily or weekly basis:
(a) The type, description, date, time of day,
duration, location and, if documenting weekly services, the frequency of
treatment, with dates of service;
(b) A description of the patient's current
symptoms and changes in functional impairment;
(c) Changes in medications taken by or
prescribed for the patient when applicable;
(d) The amount of time spent by the provider
face-to-face with the patient;
(e) The amount of time spent by the provider
in interpreting and reporting on procedures represented by "Central Nervous
System Testing" codes, when applicable;
(f) Progress notes shall include assessment
of the patient's progress or lack of progress and a brief description of the
progress made, if any, significant changes in symptoms, functioning, or events
in the life of the patient and recommendation for modifications to the
treatment plan, if applicable; and
(g) Evidence of clinical supervision, as
required.
(G)
Claim payment.
The payment amount for a behavioral health service rendered by
a community behavioral health center that meets the requirements found in rule
5160-27-01
of the Administrative Code is the lesser of the provider's submitted charge or
the amount specified in rule
5160-27-03
of the Administrative Code. For all other providers of behavioral health
services, the payment amount is the lesser of the provider's submitted charge
or the applicable percentage of the amount specified in the appendix to rule
5160-1-60 of the
Administrative Code:
(1) For testing,
one hundred per cent;
(2) For a
behavioral health service other than testing, the percentage differs according
to the provider who rendered it:
(a) For a
service rendered by a physician, an advanced practice registered nurse, a
physician assistant, or a licensed psychologist, it is one hundred per
cent.
(b) For a service rendered by
a licensed practitioner or a supervised practitioner, it is eighty-five per
cent.
(c) For a service rendered by
a supervised trainee/assistant under direct supervision, the rate of their
supervising practitioner.
(d) For a
service rendered by a supervised trainee/assistant under general supervision,
it is eighty-five per cent of the rate of their supervising
practitioner.
Notes
Ohio Admin. Code
5160-8-05
Effective:
1/1/2021
Five Year Review (FYR) Dates:
4/30/2023
Promulgated Under:
119.03
Statutory
Authority: 5164.02
Rule
Amplifies: 5164.02,
5164.03
Prior
Effective Dates: 02/17/1991, 11/01/2001, 07/01/2002, 08/17/2003, 10/01/2003,
01/01/2004, 12/30/2005 (Emer.), 03/27/2006, 01/01/2008, 12/31/2012 (Emer.),
03/28/2013, 01/01/2014, 02/01/2016, 06/30/2016 (Emer.), 10/29/2016, 01/01/2018,
01/02/2018 (Emer.), 05/03/2018, 08/01/2019 (Emer.), 11/29/2019, 06/12/2020
(Emer.)