Ohio Admin. Code 4123-6-33

Current through all regulations passed and filed through November 4, 2024

Section 4123-6-33 - Payment for health and behavior assessment and intervention services

This rule governs the bureau's reimbursement for health behavior assessment and intervention (HBAI) services offered to injured workers who may benefit from an assessment that focuses on identifying behavioral barriers impeding the injured worker's recovery which may be addressed through intervention services.

(A) An injured worker shall be eligible for consideration of HBAI services if the injured worker has the capacity to understand and respond meaningfully during the health behavior assessment process and:

(1) The injured worker's physician of record determines:

(a) The injured worker is not progressing with their injury after the initial course of treatment; and

(b) The injured worker's healing appears to be delayed due to behavioral barriers; or

(2) The injured worker is being evaluated by the physician of record, treating physician or operating surgeon for lumbar fusion surgery pursuant to rule 4123-6-32 of the Administrative Code.

References in this rule to "physician of record" shall also include the "treating physician or operating surgeon" with regard to HBAI services requested or performed in connection with lumbar fusion surgery pursuant to rule 4123-6-32 of the Administrative Code.

(B) Providers must indicate the appropriate "International Classification of Diseases, clinical modification" codes for the injured worker's allowed physical condition(s) being treated, and must utilize the applicable codes, from the edition of the centers for medicare and medicaid services' healthcare common procedure coding system (HCPCS) in effect on the date of the request, for the services being requested:

(1) Provider types who are eligible to bill evaluation and management codes must utilize evaluation and management codes when billing for HBAI services;

(2) Provider types who are not eligible to bill evaluation and management codes must utilize the applicable HBAI service codes when billing for HBAI services;

(3) HBAI services must be directed toward, and billed with, the injured worker's allowed physical condition(s);

(4) The bureau of workers' compensation shall not reimburse any HBAI services rendered to diagnose or treat psychological conditions, as the focus of these services is not on mental health but on factors impacting the prevention, treatment, or management of physical health problems and treatments.

(C) Health behavior assessment services.

(1) The physician of record requesting a health behavior assessment must submit a medical treatment reimbursement request for the assessment (on form C-9 or equivalent) to the injured worker's MCO.

(2) The physician of record must document the following to support the request for the assessment:

(a) History of the industrial injury or occupational disease resulting in the allowed conditions in the claim;

(b) Recognized behavioral barriers impeding the injured worker's recovery from the allowed conditions in the claim;

(c) Documentation of the initial course of treatment, including all treatment and diagnostic studies as of the date of the request, including all results;

(d) The assessment is not duplicative of other provider assessments.

(3) The health behavior assessment may be performed by any provider whose professional scope of practice as defined under state law includes health behavior assessment services.

(4) The provider conducting the health behavior assessment must provide a written summary report to the physician of record indicating the findings of the assessment and appropriate recommendations for intervention services, if any. The report shall include at a minimum the following:

(a) History of the industrial injury or occupational disease resulting in the allowed conditions in the claim;

(b) Overview of treatment and diagnostic studies to date and results;

(c) Use of one or more currently accepted and validated screening tools;

(d) Assessment conclusions/findings including, at a minimum:

(i) Identification and/or validation of existence of behavioral barriers;

(ii) A statement as to whether the injured worker's healing or recovery progress from the allowed conditions is impeded by the identified behavioral barriers;

(iii) Recommendation of possible intervention services and goals to address the identified behavioral barriers; and

(iv) The expected duration of the recommended intervention services;

(5) Except as otherwise provided in rule 4123-6-32 of the Administrative Code, only one health behavior assessment per year may be approved for an injured worker.

(6) Health behavior re-assessment services.

(a) One re-assessment per year may be approved for an injured worker who has undergone health behavior intervention services.

(b) A physician of record requesting a re-assessment must:

(i) Submit a medical treatment reimbursement request for the reassessment (on form C-9 or equivalent) to the injured worker's MCO; and

(ii) Provide clear rationale for why a re-assessment is required, including new and changed circumstances in the injured worker's physical status.

(7) The provider conducting the health behavior assessment or re-assessment of an injured worker may not provide health behavior intervention services for the same injured worker.

(D) Health behavior intervention services.

(1) After review of the assessment, the physician of record shall:

(a) Determine the medically necessary and appropriate health behavior intervention services to be provided; and

(b) Submit a medical treatment reimbursement request for the services (on form C-9 or equivalent) to the injured worker's MCO.

(2) The health behavior intervention services may be performed by any provider whose professional scope of practice as defined under state law includes health behavior intervention services.

(3) Health behavior intervention services are limited to coaching and counseling services that address the behavioral barriers identified or validated in the assessment.

(4) Documentation for each intervention encounter must include the following:

(a) Goals;

(b) Progress, or lack thereof, toward goals and objectives;

(c) Description of injured worker engagement; and

(d) Time in and time out and duration of services.

(5) Health behavior intervention services shall be limited to up to six hours in a twelve month period. Additional intervention services may be approved during the twelve month period, if the physician of record provides documentation the additional services are medically necessary.

Ohio Admin. Code 4123-6-33

Effective: 2/1/2022
Five Year Review (FYR) Dates: 11/12/2021 and 02/01/2027
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4131.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 07/01/2018, 06/01/2019