Ohio Administrative Code|Rule 5160-4-14 | Professional services associated with dialysis.

                                                
(A) Routine maintenance
		  dialysis.
(1) Payment for
			 professional services associated with the medical management of patients
			 receiving maintenance dialysis is made either on a monthly capitation basis or
			 on a daily basis.
(a) The monthly
				capitation payment is available to a single practitioner in the following
				circumstances:
(i) The practitioner alone provides monthly continuity of
				  services to a single patient or to a group of patients; or
(ii) The practitioner serves as the primary practitioner in
				  a joint provision (in which one person receives payment on behalf of a team of
				  practitioners).
(b) When dialysis care is
				provided by more than one practitioner in the absence of a joint provision,
				payment may be made to each practitioner separately for the days on which
				dialysis care was provided.
(c) On a submitted claim,
				the type of service payment (monthly capitation or daily care) is
				differentiated by procedure code.
(2) In addition to the payment for professional services,
			 separate payment may be made for the following services:
(a) The declotting of
				shunts; and
(b) Covered professional
				services that are unrelated to the patient's dialysis or renal
				condition.
(B) Inpatient dialysis services.
(1) Payment may be made for professional services that are
			 related to dialysis performed for a hospital inpatient for one of the following
			 reasons:
(a) Treatment of acute
				renal failure or renal trauma;
(b) Establishment of an
				initial course of dialysis (the first dialysis treatment and all subsequent
				dialysis treatments performed before the patient is stabilized on dialysis);
				or
(c) Treatment of an
				established dialysis patient who was admitted to the hospital for a condition
				or illness unrelated to the patient's renal condition.
(2) The following provisions apply to payment for
			 professional services related to inpatient dialysis:
(a) The time when the
				practitioner is present with the patient during the dialysis procedure is
				documented in the patient's medical record.
(b) On a submitted claim,
				an appropriate procedure code is used to indicate inpatient dialysis
				care.
(c) Payment for
				professional services includes all evaluation and management services related
				to the patient's renal condition. (The payment to the hospital for
				inpatient dialysis includes all other patient care services that are rendered
				during the dialysis procedure.)
(d) If a dialysis patient
				is admitted to a hospital for no reason other than to receive maintenance
				dialysis, the dialysis is considered to be routine maintenance and payment for
				professional services is made accordingly.
(C) For services rendered to a single patient in a single
		  calendar month, the following overpayments or duplicate payments are
		  disallowed:
(1) More than one monthly capitation payment;
(2) Payment for more than thirty-one days of daily dialysis
			 care; and
(3) Both the monthly capitation payment and payment for
			 daily dialysis care.


Last updated July 1, 2021 at 9:53 AM