OAR 410-146-0086: Multiple Encounters

(1) An “encounter” has the meaning given that term in OAR 410-146-0085. (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: (a) Medical (section (3) of this rule and OAR chapter 410, division 130); (b) Dental (OAR 410-146-0380 and chapter 410, division 123); (c) Behavioral Health. If a client is also seen for a medical office visit and receives a behavioral health diagnosis, then the client contacts are a single encounter. (d) Substance Use Disorder. If a client is also seen for a medical office visit and receives an addiction diagnosis, then the client’s contacts are a single encounter (refer to the Division for the appropriate OARs); (e) Ophthalmology. 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 410-146-0120); (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, behavioral health, or SUD service encounter occurs on the same date of service (OAR 410-130-0190). (j) One or more prescriptions for pharmaceuticals and biologicals not generally provided during the clinic visit that are dispensed by an IHS or Tribal 638 Pharmacy to the same individual constitute multiple encounters when delivered in a single 24-hour period ending at midnight. (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 behavioral health encounter and a SUD encounter provided to the same client on the same date of service shall 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 considered a single encounter and not multiple encounters. Services 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 behavioral health and SUD encounter with similar diagnoses; (d) A prenatal visit and a delivery procedure; (e) A cesarean delivery and surgical assist; and (f) Any time a client receives only a partial service with one provider and partial service from another provider. (6) A clinic may not develop clinic procedures that routinely involve multiple encounters for a single date of service. (7) Clinics may not “unbundle” services that are normally rendered during a single visit for the purpose of generating multiple encounters: (a) Clinics may not ask 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.