Reimbursement for ambulatory surgery center services are processed using 3M’s Enhanced Ambulatory Patient Groups (EAPG). Services provided on or after January 2, 2020 will be processed using EAPG Version 3.14. Services provided on or after August 1, 2017 and on or before January 1, 2020 will be processed using Version 3.9. Please refer to Ohio Administrative Code rule 5160-22-01 and the ambulatory surgery center billing guidelines for additional information about EAPG payment methodology.

EAPG Covered Codes (PDF) (XLSX)
Base Rate:

• $74.83 (effective 8/1/2017-1/1/2020)
• $83.34 (effective 1/2/2020-Present)

Cost-to-Charge Ratio:

• 18% (effective 8/1/2017-1/1/2020)
• 20% (effective 1/2/2020-Present)

EAPG Adjuster:

• EAPGs 134 and 149 are paid at 110% of the EAPG calculated amount (base rate x relative weight)-(effective 8/1/2027-1/1/2020)
• EAPG 233 is paid at 145% and EAPG 485 is paid at 233% of the EAPG calculated amount (base rate x relative weight) - (effective 1/2/2020-Present)

EAPG Relative Weight Table
EAPG Claim Examples

 

Effective for dates of service prior to 8/1/17.
ASC Rates – ASCs are paid a facility fee for certain procedure codes as noted in the 'Current Surgical Group' column in the ASC section of the 'Medicine, Surgery, Radiology and Imaging, and Additional Procedures (Non-Institutional Services)' schedule.

This table (PDF) lists the current payment amounts for anesthesia administration. It reflects the policy set forth in Ohio Administrative Code rule 5160-4-21.

• CPT and HCPCS level II procedure codes that were added or discontinued as of January 1, 2020
• CPT and HCPCS level II procedure codes that were added or discontinued as of July 1, 2019
• CPT and HCPCS level II procedure codes that were added or discontinued as of January 1, 2019
• CPT and HCPCS level II procedure codes that were added or discontinued as of January 1, 2018
• CPT and HCPCS level II procedure codes that were added or discontinued as of January 1, 2017
• 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

This table (PDF) lists the current fees for Current Dental Terminology (CDT) procedure codes. It reflects the policy set forth in Ohio Administrative Code rule 5160-5-01.

The main DMEPOS payment schedule lists the current maximum payment amounts for many durable medical equipment items, prostheses, orthoses, and medical supplies. It reflects the policy set forth in Ohio Administrative Code Chapter 5160-10. (XLSX)

The Oxygen payment schedule lists the current maximum payment amounts for oxygen. It reflects the policy set forth in Ohio Administrative Code rule 5160-10-13. (XLSX)

The Wheelchair payment schedule lists the current maximum payment amounts for wheelchairs, parts, accessories, and related services. It reflects the policy set forth in Ohio Administrative Code rule 5160-10-16. (XLSX)

This table (XLSX) lists the current composite payment amounts for ESRD dialysis clinics.  It reflects the policy set forth in Ohio Administrative Code rule 5160-13-02.

This table (XLSX) lists the current amounts for eye care services.  It reflects the policy set forth in Ohio Administrative Code rule 5160-6-01.

The fee schedule for Home and Community Based Services can be found at: Chapters 5123:2-9/5123-9 Home and Community-Based Services Waiver

• January 1, 2017 and forward
• January 1, 2016 – December 31, 2016
• July 1, 2015 to December 31, 2015
• January 1, 2010 – September 30, 2011 and October 1, 2011 – June 30,2015

• Hospice Rates FFY 2021 – October 1, 2020 - September 30, 2021 for Providers in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2021 – October 1, 2020 - September 30, 2021 for Providers not in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2020 – October 1, 2019 - September 30, 2020 for Providers in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2020 – October 1, 2019 - September 30, 2020 for Providers not in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2019 – October 1, 2018 – September 30, 2019 for Providers in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2019 – October 1, 2018 – September 30, 2019 for Providers not in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2018 – October 1, 2017 – September 30, 2018 for Providers in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2018 – October 1, 2017 – September 30, 2018 for Providers not in Compliance with Hospice Quality Reporting Requirements
• Hospice Rates FFY 2017 – October 1, 2016 – September 30, 2017 for Providers that Comply with Quality Data Reporting Requirements
• Hospice Rates FFY 2017 – October 1, 2016 – September 30, 2017 for Providers that Failed to Comply with Quality Reporting Requirements
• 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

• DRG Relative Weight Tables
• Hospital Base Rates 
• Inpatient Services that Require Prior Authorization
• Other Hospital Provider Information

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.

• The fee schedule for Behavioral Health services effective 1/1/2018 can be found here: http://bh.medicaid.ohio.gov/manuals. It is published as the appendix to rule 5160-27-03 of the Administrative Code.

This schedule (PDF) - (XLSX) 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.

Nursing Facility Rates

Reimbursement for outpatient hospital services are processed using 3M’s Enhanced Ambulatory Patient Groups (EAPG). Services provided on or after January 2, 2020 will be processed using EAPG Version 3.14. Services provided on or after August 1, 2017 and on or before January 1, 2020 will be processed using Version 3.9. Please refer to Ohio Administrative Code rule 5160-2-75 and the hospital billing guidelines for additional information about EAPG payment methodology.

• EAPG Covered Codes (PDF) (XLSX) (Telehealth)
• EAPG Relative Weights
• Hospital Base Rates
• Other Hospital Provider Information

 

The Outpatient Fee Schedules are several Appendices of Ohio Administrative Code Rule 5160-2-21, effective through 7/31/17.

 

• Addendum (PDF) - (XLS) CPT Code Changes Effective 1/1/2017. This Addendum should be used in tandem with the 10/1/2016 appendices to determine coverage of procedure codes for dates of service on or after 1/1/2017. 

The following fee schedules are applicable for dates of service on or after 10/1/2016:

• 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 Laboratory Services Fee Schedule for coverage and reimbursement rates of laboratory codes. Please refer to Appendix DD for reimbursement rate of CPT code 36416 (capillary blood draw).
  • Appendix H (PDF) - (XLS) Outpatient Hospital Laboratory Fee Schedule (for dates of service on or before 12/31/2015).
• Appendix I (PDF) - (XLS) HCPCS Q-Codes Covered in an Outpatient Hospital Setting.

 

 

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 Laboratory Services Fee Schedule for coverage and reimbursement rates of laboratory codes. Please refer to Appendix DD for reimbursement rate of CPT code 36416 (capillary blood draw).

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

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

The following information pertains to Behavioral Health Services provided by an outpatient hospital for dates of service on or after August 1, 2017:

• Overview of Outpatient Hospital Behavioral Health Services (Revised 1/22/19)
• Outpatient Hospital Behavioral Health Codes and Rates (Revised 1/30/2020)
• Modifiers for Outpatient Behavioral Health (Revised 7/24/19)
• Revenue Center Codes (Revised 4/30/20)
• Outpatient Hospital Behavioral Health Diagnosis Codes (Revised 9/25/20)

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.

2014

• PDF
• XLS

2013

• PDF 
• XLS 

• January 1, 2017 and forward
• July 1, 2015 – December 31, 2016
• January 1, 2010 – September 30, 2011 and October 1, 2011 – June 30, 2015

This table (XLS) 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.

• July 1, 2015 and forward

The rates for targeted case management can be found at: TCM

This table (PDF) lists the current payment amounts for transportation by ambulance or wheelchair van. It reflects the policy set forth in Ohio Administrative Code rule 5160-15-28.