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Fee Schedules and Rates

Ambulatory Surgical Centers

ASC Rates – ASCs are paid a facility fee for certain procedure codes as noted in the “Current Surgical Group” column of the Medicaid Non-Institutional Maximum Payment Schedule.

CPT and HCPCS Level II Procedure Code Changes

CPT and HCPCS level II procedure codes that were added or discontinued as of January 1, 2016

CPT and HCPCS level II procedure codes that were added or discontinued as of January 1, 2015

Durable Medical Equipment

Prescriptions for DME, medical supplies, orthotics or prosthetics must have originated as a result of a face-to-face encounter between the prescriber and the consumer. This encounter must occur no more than 180 days to the prescription being written and cannot occur following the date the prescription is written. (XLS)

Use of either the RT or LT modifiers is required when billing for the codes for items having the same billing code and dispensed bilaterally on the same date of service for the same consumer, both the RT and the LT modifier must be used. (XLS)

Freestanding Birthing Centers

These providers are reimbursed for specific procedure codes as detailed in the Appendix of Ohio Administrative Code Rule 5101:3-18-01.

Home and Community-Based Services Waiver Fee Schedule

Home Health Rates

Hospice Rates

  • Hospice Rates FFY 2016 – October 1, 2015 – September 30, 2016 for Providers that Comply with Quality Data Reporting Requirements
  • Hospice Rates FFY 2016 – October 1, 2015 – September 30, 2016 for Providers that Failed to Comply with Quality Reporting Requirements
  • Hospice Rates FFY 2015 – October 1, 2014 – September 30, 2015 for Providers that Comply with Quality Data Reporting Requirements
  • Hospice Rates FFY 2015 – October 1, 2014 – September 30, 2015 for Providers that Failed to Comply with Quality Reporting Requirements
  • Hospice Rates FFY 2014 – October 1, 2013 – September 30, 2014 for Providers that Have Submitted Required Quality Data to Medicare
  • Hospice Rates FFY 2014 – October 1, 2013 – September 30, 2014 for Providers that Have NOT Submitted Required Quality Data to Medicare
  • Hospice Rates FFY 2013 – October 1, 2012 – September 30, 2013

Inpatient Hospital Services

Laboratory Services

This table (PDF) (XLSX) lists the current coverage and maximum payment amounts for clinical diagnostic procedures, pathology procedures, and related services.  It reflects the policy set forth in Chapter 5160-11 of the Ohio Administrative Code.

Medicaid Non-Institutional Maximum Payment Schedule

This schedule (PDF) - (XLS) applies to most non-institutional fee-for-service providers.  It is published as Appendix DD to rule 5160-1-60 of the Ohio Administrative Code.

Medicaid Fee Schedule for Community Behavioral Health Providers (OhioMHAS Administered)

Outpatient Hospital Services

The Outpatient Fee Schedules are several Appendices of Ohio Administrative Code Rule 5160-2-21.

The following fee schedules are applicable for dates of service on or after 1/1/2016:

  • Addendum (PDF) - (XLS) CPT Code Changes Effective January 1, 2016.
  • Appendix A (PDF) - (XLS) Local Level Codes & Modifiers.
  • Appendix B (PDF) - (XLS) Revenue Center Codes Requiring CPT or HCPCS Coding.
  • Appendix C (PDF) - (XLS) Ambulatory Surgery Fee Schedule.
  • Appendix D (PDF) - (XLS) Clinic Facility Fee Schedule.
  • Appendix E (PDF) - (XLS) Emergency Room Fee Schedule.
  • Appendix F (PDF) - (XLS) Ancillary Fee Schedule.
  • Appendix G (PDF) - (XLS) Outpatient Hospital Radiology Fee Schedule.
  • Appendix H Outpatient Hospital Laboratory Fee Schedule has been rescinded. Please refer to the Medicaid Non-Institutional Maximum Payment Schedule for coverage and reimbursement rates of laboratory codes.

The following fee schedules are applicable for dates of service on or after 4/30/2015 through 12/31/2015: 

  • Appendix A (PDF) - (XLS) Local Level Codes & Modifiers.
  • Appendix B (PDF) - (XLS) Revenue Center Codes Requiring CPT or HCPCS Coding.
  • Appendix C (PDF) - (XLS) Ambulatory Surgery Fee Schedule.
  • Appendix D (PDF) - (XLS) Clinic Facility Fee Schedule.
  • Appendix E (PDF) - (XLS) Emergency Room Fee Schedule.
  • Appendix F (PDF) - (XLS) Ancillary Fee Schedule.
  • Appendix G (PDF) - (XLS) Outpatient Hospital Radiology Fee Schedule
  • Appendix H (PDF) - (XLS) Outpatient Hospital Laboratory Fee Schedule (for services on or after Jan. 1, 2010)

Pharmacy

Pharmacy providers are paid as described in OAC rules 5160-9-05 (drugs including influenza vaccine) and 5160-9-02 (supplies).  Visit Ohio Medicaid Pharmacy website for a searchable database of pharmacy coverage and rates.

Primary Rate Increase

2014 2013

Private Duty Nursing Rates

Provider-Administered Pharmaceuticals

This table (PDF) lists the current coverage and fees for vaccines, injectable medications, and other drugs administered by practitioners. It reflects the policy set forth in the Ohio Administrative Code in rule 5160-4-12.

RN Assessment and RN Consultation Services

Targeted Case Management

Provider Hotline

MITS Portal