Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-11 - Independent Laboratory and X-Ray Services › Section 5160-11-11 - Laboratory services

Current through all regulations passed and filed through July 1, 2024
(A)
								Definitions and
			 explanations that apply to this chapter of the Administrative Code.
(1)
									"Clinical
			 consultation" is the formal evaluation by a physician or other qualified
			 healthcare professional, performed on the written order of a treating
			 practitioner, of test results that appear to be abnormal. Payment for the
			 clinical consultation is based on the physician fee schedule relative value
			 file published by the centers for medicare and medicaid services (CMS). (The
			 procedure code used for clinical consultation is different and separate from
			 the procedure code for the test whose results are being
			 evaluated.)
(2)
									"Clinical pathology interpretation" is the
			 interpretation, performed on the written order of a treating practitioner by
			 another practitioner, of the results of any of a certain group of clinical
			 diagnostic procedures that are distinguished by three shared traits:
(a)
										Separate payment
			 may be made for interpretation;
(b)
										Payment for the
			 clinical diagnostic procedures themselves is based on the clinical laboratory
			 fee schedule published by CMS; and
(c)
										Payment for the
			 clinical pathology interpretation is based on the physician fee schedule
			 relative value file published by CMS. (The procedure code for the clinical
			 pathology interpretation consists of a professional component modifier appended
			 to the relevant clinical diagnostic procedure code.)
(3)
									"Eligible
			 provider" has the same meaning as in rule
			 5160-1-17 of
			 the Administrative Code.
(4)
									"Global procedure" or "total procedure" is a procedure,
			 in its entirety, that comprises both a technical component (the part of a
			 laboratory procedure that relies on the technical skill of a trained individual
			 to secure a specimen and prepare it for analysis) and a professional component
			 (the part of a laboratory procedure that relies on the professional skill or
			 training of a physician or other qualified healthcare professional to analyze
			 the results produced by the technical component and to provide a written report
			 of findings).
(5)
									"Independent" means separate from an attending or
			 consulting practitioner's office or group practice, an ambulatory surgery
			 center, a hospital, or a nursing facility. A laboratory facility under the
			 ownership and direction of an individual practitioner or group practice is
			 considered to be independent if it is represented to other practitioners that
			 both the owners and directors and the facility itself are available for the
			 performance of procedures.
(6)
									"Routine
			 procedure" is a procedure for which no separate payment is made for either of
			 two reasons:
(a)
										It is very common and is performed only in connection
			 with another procedure (e.g., the collection of a clean-catch urine sample or a
			 throat swab); or
(b)
										It is included in a treatment protocol for which a
			 composite payment amount has been established (e.g., a specific laboratory test
			 performed for an individual receiving dialysis, the reading by automated
			 glucose monitor of blood samples taken from nursing facility residents who have
			 diabetes).
(7)
									For purposes of medicaid, most covered laboratory
			 procedures fall into two main categories.
(a)
										 For the
			 performance of clinical diagnostic procedures, no highly specialized skill is
			 needed (such as the knowledge and training of a physician or other qualified
			 healthcare professional).
(i)
											Clinical diagnostic procedures have no separate
			 professional and technical components.
(ii)
											Performance of
			 these procedures is generally predicated on certification of the laboratory
			 provider under the "Clinical Laboratory Improvement Amendments of 1988" (CLIA,
			 Pub. L. No. 100-578,
			 42 U.S.C.
			 263a as in effect on January 1,
			 2021).
(iii)
											Payment for these procedures is based on the clinical
			 laboratory fee schedule published by CMS.
(b)
										The performance
			 of professional procedures relies on the skill and training of a physician or
			 other qualified healthcare professional, usually a pathologist or a
			 hematologist.
(i)
											Pathology procedures have both a professional component
			 and a technical component. In most instances, these components are
			 distinguished on claims by the inclusion of a modifier along with the procedure
			 code. (The professional and technical components of a few procedures may be
			 represented by separate procedure codes.) The professional component of a
			 pathology procedure represents the professional services a practitioner renders
			 in the performance of the procedure. It does not represent the simple reading
			 of test results, which is included in the associated originating service (e.g.,
			 office visit or surgery).
(ii)
											Some procedures
			 are exclusively professional in nature and have no technical
			 component.
(iii)
											Only an eligible practitioner or an independent
			 laboratory submitting claims on behalf of its eligible practitioners may
			 receive payment for a professional procedure (or a professional component of a
			 procedure).
(iv)
											Payment for pathology procedures and for other
			 professional procedures or components of procedures is based on the physician
			 fee schedule relative value file published by CMS. (There are a very few
			 exclusively technical procedures for which payment is also based on the
			 physician fee schedule relative value file.)