Or. Admin. Code § 410-147-0140 - Multiple Encounters
(1) An
encounter is defined in OAR
410-147-0120.
(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 (see OAR
410-147-0120 and individual
program rules listed below for specific service requirements and limitations):
(a) Medical section (3) of this rule and OAR
chapter 410, division 130);
(b)
Dental (OAR 410-147-0125, and OAR chapter
410, division 123);
(c) Mental
Health - If a client is also seen for a medical office visit and receives a
mental health diagnosis, then the client contacts are a single encounter (Refer
to the Division of Addictions and Mental Health (AMH) for the appropriate
OARs);
(d) Addiction and Alcohol
and Chemical Dependency - If a client is also seen for a medical office visit
and receives an addiction diagnosis, then the client contacts area single
encounter (Refer to AMH's OARs);
(e) Ophthalmologic services - 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
410-147-0200);
(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, mental health or addiction service encounter occurs on the same date of
service (refer to OAR
410-130-0190).
(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 mental health encounter and an
addiction and alcohol and chemical dependency encounter provided to the same
client on the same date of service will 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 not considered multiple encounters. Situations 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 mental health and addiction encounter
with similar diagnoses;
(d) A
prenatal visit and a delivery procedure;
(e) A cesarean delivery and surgical
assist;
(f) Any time a client
receives only a partial service with one provider and partial service from
another provider, this would be considered a single encounter.
(6) A clinic may not develop
clinic procedures that routinely involve multiple encounters for a single date
of service. A recipient may obtain medical, dental or other health services
from any provider approved by the Division, and/or contracts with the
recipient's PHP, if the FQHC/RHC is not the recipient's primary care
manager.
(7) Clinics may not
"unbundle" services that are normally rendered during a single visit for the
purpose of generating multiple encounters:
(a) Clinics are prohibited from asking 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
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
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