Ohio Admin. Code 5160-1-18 - Telehealth

(A) For the purposes of this rule, the following definitions apply:

(1) "Patient site" is the physical location of the patient at the time a health care service is provided through the use of telehealth.

(2) "Practitioner site" is the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

(3) "Telehealth" is the direct delivery of health care services to a patient related to diagnosis, treatment, and management of a condition.

(a) Telehealth is the interaction with a patient via synchronous, interactive, real-time electronic communication comprising both audio and video elements; or

(b) The following activities that are asynchronous or do not have both audio and video elements:

(i) Telephone calls;

(ii) Remote patient monitoring; and

(iii) Communication with a patient through secure electronic mail or a secure patient portal.

(c) For services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is defined in rule 5122-29-31 of the Administrative Code.

(d) Conversations or electronic communication between practitioners regarding a patient without the patient present is not considered telehealth unless the service would allow billing for practitioner to practitioner communication in a non-telehealth setting.

(B) Eligible providers.

(1) The following practitioners are eligible to render services through the use of telehealth:

(a) Physician Physicians as defined in Chapter 4731. of the Revised Code.

(b) Psychologist Psychologists as defined in Chapter 4732. of the Revised Code.

(c) Physician assistant assistants as defined in Chapter 4730. of the Revised Code.

(d) Clinical nurse specialist specialists, certified nurse-midwife midwives, or certified nurse practitioner practitioners as defined in Chapter 4723. of the Revised Code.

(e) Licensed independent social worker workers, licensed independent marriage and family therapist therapists, or licensed professional clinical counselor counselors as defined in Chapter 4757. of the Revised Code.

(f) Licensed independent chemical dependency counselor counselors as defined in Chapter 4758. of the Revised Code.

(g) Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-05 5160-4-02 and 5160-8-05 of the Administrative Code.

(h) Audiologist Audiologists, speech-language pathologist pathologists, speech-language pathology aides, audiology aides, and individuals holding a conditional license as defined in Chapter 4753. of the Revised Code.

(i) Occupational and physical therapist therapists and occupational and physical therapist assistants as defined in Chapter 4755. of the Revised Code.

(j) Home health and hospice aides.

(k) Private duty registered nurse nurses or licensed practical nurse nurses in a home health or hospice setting.

(l) Dentists as defined in Chapter 4715. of the Revised Code.

(m) Medicaid school program (MSP) practitioners as described in Chapter 5160-35 of the Administrative Code.

(n) Dietitians as defined in Chapter 4759. of the Revised Code.

(o) Behavioral health practitioners as defined in rule 5160-27-01 of the Administrative Code.

(p) Optometrists as defined in Chapter 4725. of the Revised Code.

(q) Pharmacists as defined in Chapter 4729. of the Revised Code.

(q)(r) Other practitioners if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(2) The following provider types are eligible to bill for services rendered through the use of telehealth.

(a) Any practitioner identified in paragraph (B)(1) of this rule, except for the following dependent practitioners:

(i) Supervised practitioners, trainees, residents, and interns as defined in rules 5160-4-02 and 5160-8-05 of the Administrative Code;

(ii) Occupational therapist assistant assistants as defined in section 4755.04 of the Revised Code;

(iii) Physical therapist assistant assistants as defined in section 4755.40 of the Revised Code;

(iv) Speech-language pathology aides, audiology aides, and individuals holding a conditional license as defined in Chapter 4753. of the Revised Code.

(b) A professional medical group.

(c) A professional dental group.

(d) A federally qualified health center (FQHC) or rural health clinic (RHC) as defined in Chapter 5160-28 of the Administrative Code.

(e) Ambulatory health care clinics (AHCC) as defined in Chapter 5160-13 of the Administrative Code.

(f) Outpatient hospitals on behalf of licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting.

(g) Medicaid school program (MSP) providers as defined in Chapter 5160-35 of the Administrative Code.

(h) Private duty nurses.

(i) Home health and hospice agencies.

(j) Behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code.

(k) Hospitals operating an outpatient hospital behavioral health program in accordance with rule 5160-2-76 of the Administrative Code.

(C) Provider responsibilities when providing services through telehealth.

(1) It is the responsibility of the practitioner to deliver telehealth services in accordance with all state and federal laws including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any HIPAA related directives from the office for civil rights (OCR) at the department of health and human services (HHS) issued during the COVID-19 national public health emergency and 42 C.F.R. part 2 (January 1, 2020).

(2) It is the responsibility of the practitioner to deliver telehealth services in accordance with rules set forth by their respective licensing board and accepted standards of clinical practice.

(3) The practitioner site is responsible for maintaining documentation in accordance with paragraph (C)(1) of this rule for the health care service delivered through the use of telehealth and to document the specific telehealth modality used.

(4) For practitioners who render services to an individual through telehealth for a period longer than twelve consecutive months, the telehealth practice or practitioner is expected to conduct at least one in-person annual visit or refer the individual to a practitioner or their usual source of clinical care that is not an emergency department for an in-person annual visit.

(D) Payment may be made only for the following medically necessary health care services identified in appendix A to this rule when delivered through the use of telehealth from the practitioner site:

(1) When provided by a patient centered medical home as defined in rule 5160-19-01 of the Administrative Code or behavioral health provider as defined in rule 5160-27-01 of the Administrative Code, evaluation and management of a new patient described as "office or other outpatient visit" with medical decision making not to exceed moderate complexity.

(2) Evaluation and management of an established patient described as "office or other outpatient visit" with medical decision making not to exceed moderate complexity.

(3) Inpatient or office consultation for a new or established patient when providing the same quality and timeliness of care to the patient other than by telehealth is not possible, as documented in the medical record.

(4) Mental health or substance use disorder services described as "psychiatric diagnostic evaluation" or "psychotherapy."

(5) Remote evaluation of recorded video or images submitted by an established patient.

(6) Virtual check-in by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient.

(7) Online digital evaluation and management service for an established patient.

(8) Remote patient monitoring.

(9) Audiology, speech-language pathology, physical therapy, and occupational therapy services, including services provided in the home health setting.

(10) Medical nutrition services.

(11) Lactation counseling services.

(12) Psychological and neuropsychological testing.

(13) Smoking and tobacco use cessation counseling.

(14) Developmental test administration.

(15) Limited or periodic oral evaluation.

(16) Hospice services.

(17) Private duty nursing services.

(18) State plan home health services.

(19) Dialysis related services.

(20) Services under the specialized recovery services (SRS) program as defined in rule 5160-43-01 of the Administrative Code.

(21) Notwithstanding paragraph (D)(2) of this rule, behavioral health services covered under Chapter 5160-27 of the Administrative Code.

(22) Optometry services.

(23) Pregnancy education services.

(24) Diabetic self-management training (DSMT) services.

(25) Other services if specifically authorized in rule promulgated under agency 5160 of the Administrative Code.

(E) Submission and payment of telehealth claims.

(1) The practitioner site may submit either a professional or institutional claim for health care services delivered through the use of telehealth. For any professional claim submitted for health care services utilizing telehealth to be paid, it is the responsibility of the provider to follow ODM billing guidelines found on the ODM website: www.medicaid.ohio.gov .

(2) An institutional (facility) claim may be submitted by an outpatient hospital for telehealth services provided by licensed psychologists and independent practitioners not eligible to separately bill when practicing in an outpatient hospital setting. Other telehealth services provided in a hospital setting may be billed in accordance with rule 5160-2-02 of the Administrative Code.

(3) Medicaid-covered services may be provided through telehealth, as appropriate, if otherwise payable under the medicaid school program as defined in Chapter 5160-35 of the Administrative Code.

(4) Except for services billed by behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code and FQHC and RHC services defined in rules 5160-28-03.1 and 5160-28- 03.3 of the Administrative Code, the payment amount for a health care service delivered through the use of telehealth is the lesser of the submitted charge or the maximum amount shown in appendix DD to rule 5160-1-60 of the Administrative Code for the date of service.

(5) For a covered telehealth service that is also an FQHC or RHC service, the face-to-face requirement is waived and payment is made in accordance with Chapter 5160-28 of the Administrative Code.

(6) Individuals who meet the definition of inmate in a penal facility or a public institution as defined in rule 5160:1-1-03 of the Administrative Code are not eligible for telehealth services under this rule.

(7) For any professional claim submitted for health care services utilizing telehealth to be paid, it is the responsibility of the provider to follow ODM billing guidelines found on the ODM website, www.medicaid.ohio.gov.

(8)(7) For telehealth services billed by behavioral health providers as defined in paragraphs (A)(1) and (A)(2) of rule 5160-27-01 of the Administrative Code, payment is made in accordance with Chapter 5160-27 of the Administrative Code.

(9)(8) Unless stated otherwise in the billing guidelines, professional claims submitted for health care services utilizing provided through the use of telehealth must have to include:

(a) A "GT" modifier;

(b) A place of service code that reflects the physical location of the treating practitioner at the time a health care service is provided through the use of telehealth.

(c) A modifier as identified in appendix B to this rule if the physical location of the patient is one of the following locations:

(i) The patient's home (including homeless shelter, assisted living facility, group home, and temporary lodging);

(ii) School;

(iii) Inpatient hospital;

(iv) Outpatient hospital;

(v) Nursing facility;

(vi) Intermediate care facility for individuals with an intellectual disability.

(10) Procedure codes for eligible telehealth services are listed in appendix A to this rule. To qualify for payment, a service should:

(a) Be clinically appropriate;

(b) Meet professional standards of care;

(c) Be rendered in accordance with the scope of licensure; and

(d) Be rendered in accordance with the standards of practice for the provider's respective licensure.

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Notes

Ohio Admin. Code 5160-1-18

Effective: 7/15/2022
Five Year Review (FYR) Dates: 11/15/2025
Promulgated Under: 119.03
Statutory Authority: 5164.02, 5164.95
Rule Amplifies: 5164.02, 5164.95
Prior Effective Dates: 01/02/2015, 07/04/2019, 07/16/2020 (Emer.), 11/15/2020