Or. Admin. Code § 410-146-0086 - Multiple Encounters
(1) An
"encounter" has the meaning given that term in OAR
410-146-0085.
(2) The following services may be considered
as multiple encounters when two or more service encounters are provided on the
same date of service with distinctly different diagnoses:
(a) Medical (section (3) of this rule and OAR
chapter 410, division 130);
(b)
Dental (OAR 410-146-0380 and chapter 410,
division 123);
(c) Behavioral
Health. If a client is also seen for a medical office visit and receives a
behavioral health diagnosis, then the client contacts are a single
encounter.
(d) Substance Use
Disorder. If a client is also seen for a medical office visit and receives an
addiction diagnosis, then the client's contacts are a single encounter (refer
to the Division for the appropriate OARs);
(e) Ophthalmology. Fitting and dispensing of
eyeglasses are included in the encounter when the practitioner performs a
vision examination. (OAR chapter 410, division 140);
(f) Maternity Case Management (MCM) (OAR
410-146-0120);
(g) Physical or occupational therapy (PT/OT).
If this service is also performed on the same date of service as the medical
encounter that determined the need for PT/OT (initial referral), then it is
considered a single encounter (OAR chapter 410, division 131);
(h) Immunizations. If no other medical office
visit occurs on the same date of service; and
(i) Tobacco cessation. If no other medical,
dental, behavioral health, or SUD service encounter occurs on the same date of
service (OAR 410-130-0190).
(j) One or more prescriptions for
pharmaceuticals and biologicals not generally provided during the clinic visit
that are dispensed by an IHS or Tribal 638 Pharmacy to the same individual
constitute multiple encounters when delivered in a single 24-hour period ending
at midnight.
(3)
Encounters with more than one health professional and multiple encounters with
the same health professional that take place on the same day and that share the
same or like diagnoses constitute a single encounter, except when one of the
following conditions exist:
(a) After the
first medical service encounter, the patient suffers a distinctly different
illness or injury requiring additional diagnosis or treatment. More than one
office visit with a medical professional within a 24-hour period and receiving
distinctly different diagnoses may be reported as two encounters. This does not
imply that if a client is seen at a single office visit with multiple problems
that the provider can bill for multiple encounters;
(b) The patient has two or more encounters as
described in section (2) of this rule.
(4) A behavioral health encounter and a SUD
encounter provided to the same client on the same date of service shall only
count as multiple encounters when provided by two separate health professionals
and each encounter has a distinctly different diagnosis.
(5) Similar services even when provided by
two different health care practitioners are considered a single encounter and
not multiple encounters. Services that would not be considered multiple
encounters provided on the same date of service include, but are not limited
to:
(a) A well child check and an
immunization;
(b) A well child
check and fluoride varnish application in a medical setting;
(c) A behavioral health and SUD encounter
with similar diagnoses;
(d) A
prenatal visit and a delivery procedure;
(e) A cesarean delivery and surgical assist;
and
(f) Any time a client receives
only a partial service with one provider and partial service from another
provider.
(6) A clinic
may not develop clinic procedures that routinely involve multiple encounters
for a single date of service.
(7)
Clinics may not "unbundle" services that are normally rendered during a single
visit for the purpose of generating multiple encounters:
(a) Clinics may not ask the patient to make
repeated or multiple visits to complete what is considered a reasonable and
typical office visit, unless it is medically necessary to do so;
(b) Medical necessity must be clearly
documented in the patient's record.
Notes
Tables referenced are available from the agency.
Statutory/Other Authority: ORS 413.042 & ORS 414.065
Statutes/Other Implemented: ORS 414.065
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