Provider Guide - Washington State Health Care Authority

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Physician-Related Services/ Health Care Professional Services

Provider Guide April 1, 2016

Physician-Related Services/Health Care Professional Services

About this guide* This publication takes effect April 1, 2016, and supersedes earlier guides to this program. Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and stateonly funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority.

What has changed? Subject Important Changes to Apple Health Effective April 1, 2016

Naltrexone injections (Vivitrol)

Sterilizations

Billing for sterilization Behavioral Health Organization

*

Change Effective April 1, 2016, important changes are taking place that all providers need to know. Information has been added regarding new policy for early enrollment into managed care, implementation of fully integrated managed care in SW WA Region, Apple Health Core Connections for Foster Children, Behavioral Health Organizations (formerly RSNs), and contact information for southwest Washington. Added “with prior authorization” to be consistent with the injectable fee schedule, as well as information about HCA 13331form. Also added this information in another reference to Vivitrol. Removed references to hysteroscopic sterilizations, and directed readers to the Sterilization Supplemental Provider Guide. Removed codes and pointed readers to the Sterilization Supplemental Provider Guide. Removed all references to regional support networks (RSN) and changed them to behavioral health organizations (BHO). This change aligns with new rules under Chapter 182-538A, 182-538B, 182-538C, and WSR 16-06-053 effective April 1, 2016.

This publication is a billing instruction. 2

Reason for Change Program changes

Clarification

Streamlining information Streamlining information New terminology

Physician-Related Services/Health Care Professional Services Subject

Change

Payment for smoking cessation referral

Removed “the client is evaluated, in person, for the sole purpose of counseling the client to encourage them to call and enroll in this smoking cessation program.” Also added a clarification about reimbursements and information about the T1016 procedure code.

Smoking cessation referral for an evaluation for a smoking cessation prescription

Added that the referral is not billed in combination with an evaluation and management office visit. Replaced “physicians and ARNPS” with “prescriber.”

Clarification of policy

ICD code Z36

Removed code.

Rhinosinusitis

Imaging for rhinosinusitis is a covered benefit.

Sleep medicine testing (sleep apnea)

Coverage for clients age 21 and older, or 20 and younger, is now 18 and older, and 17 and younger, respectively.

Sleep medicine testing (sleep apnea)

For clients age 17 and younger, the agency covers a full-night or split- night in a laboratory PSG.

Sleep study billing

Provided detailed billing instructions. Remove CPT codes 95782, 95783, 95805, and 95807-95811 for sleep study services. Refered readers to the fee schedules. Removed code.

This code is not relevant to the section content. Health Technology Assessment (HTA) Program decision Clarifying prior Health Technology Assessment (HTA) Program decision. Clarifying prior Health Technology Assessment (HTA) Program decision. Clarification

HCPCS procedure code C1718

Reason for Change Clarification of policy

The code was discontinued

Who is eligible for telemedicine?

Added clarifying language.

Clarification

EPA #870001381

Added EPA #870001381 for HPV genotyping.

New EPA code

Bone morphogenetic protein 2 for lumbar fusion

Lumbar fusion is not covered for clients with a diagnosis of degenerative disc disease

Clarification

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Physician-Related Services/Health Care Professional Services Subject

Change

Reason for Change

Auditory system

Tympanostomies for clients diagnosed with acute otitis media or otitis media with effusion is covered. Expedited prior authorization (EPA) is required. See EPA #870001382.

Health Technology Assessment (HTA) Program decision

Place of Service Code 19

Added place of service code 19 for “Off Campus-Outpatient Hospital”

SBIRT

Added diagnosis code Z71.51 to list of allowable codes

CMS-1500 claim form

Updated information under “How do I complete the CMS-1500 claim form.” Removed links to webinars. Providers should refer to the Provider Training page, Medicaid 101 for electronic billing information.

New definition added to POS 19 by CMS effective Jan 1, 2016. Correction to add a code that was missed Webinars no longer available

Newborn care

Added information about newborn screening tests

Clarification

Percutaneous pulmonary valve implantation

New coverage and prior authorization for PPVI

New coverage

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Physician-Related Services/Health Care Professional Services

How can I get agency provider documents? To download and print agency provider notices and provider guides, go to the agency’s Provider Publications website.

Copyright disclosure Current Procedural Terminology (CPT) copyright 2015, American Medical Association (AMA). All rights reserved. CPT® is a registered trademark of the American Medical Association. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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Physician-Related Services/Health Care Professional Services

Table of Contents Who is eligible for telemedicine? ......................................................................................3 Bone morphogenetic protein 2 for lumbar fusion...........................................................3 Auditory system .......................................................................................................................4 Place of Service Code 19 ..........................................................................................................4 Important Changes to Apple Health Effective April 1, 2016 ...................................................19 New MCO enrollment policy – earlier enrollment ..................................................................19 How does this policy affect providers? ..............................................................................20 Behavioral Health Organization (BHO) ..................................................................................20 Fully Integrated Managed Care (FIMC) ..................................................................................20 Apple Health Core Connections (AHCC)................................................................................21 AHCC complex mental health and substance use disorder services .................................22 Contact Information for Southwest Washington .....................................................................22 Definitions .....................................................................................................................................23 Introduction ..................................................................................................................................26 Acquisition cost .......................................................................................................................26 Add-on codes ...........................................................................................................................26 By report ..................................................................................................................................26 Codes for unlisted procedures ..................................................................................................27 Conversion factors ...................................................................................................................27 Diagnosis codes .......................................................................................................................27 Discontinued codes ..................................................................................................................27 National correct coding initiative.............................................................................................28 Procedure codes .......................................................................................................................28 Provider Eligibility.......................................................................................................................29 Who may provide and bill for physician-related services? ......................................................29 Can naturopathic physicians provide and bill for physician-related services? ........................30 Can substitute physicians (locum tenens) provide and bill for physician-related services? .............................................................................................................................31 Resident Physicians ...........................................................................................................31 Which health care professionals does the agency not enroll? ..................................................32 Does the agency pay for out-of-state hospital admissions? .....................................................33 Client Eligibility ...........................................................................................................................34 How can I verify a patient’s eligibility? ..................................................................................34 Are clients enrolled in an agency-contracted managed care organization (MCO) eligible? ..............................................................................................................................35 Are clients enrolled in hospice eligible for services? ..............................................................35

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Physician-Related Services/Health Care Professional Services Coverage - General ......................................................................................................................36 What is covered? ......................................................................................................................36 Does the agency cover nonemergency services provided out-of-state? ..................................38 What services are noncovered? ................................................................................................38 General information ...........................................................................................................38 Noncovered physician-related and health care professional services ................................39 Medical Policy Updates ...............................................................................................................41 Policy updates effective 4/1/2016 ............................................................................................41 Policy updates effective 10/1/2015 ..........................................................................................41 Policy updates effective 7/1/2015 ............................................................................................41 Policy updates effective 4/1/2015 ............................................................................................41 Policy updates effective 1/1/2015 ............................................................................................41 Evaluation and Management ......................................................................................................43 Evaluation and management documentation and billing .........................................................43 Advance directives/physician orders for life-sustaining treatment ..........................................44 Telephone services ...................................................................................................................45 Partnership Access Line ...........................................................................................................46 Office and other outpatient services ........................................................................................46 Office or other outpatient visit limits .................................................................................46 New patient visits ...............................................................................................................46 Established patient visits ....................................................................................................47 Nursing facility services ....................................................................................................47 Pre-operative visit prior to performing a dental service under anesthesia .........................47 Physical examination - clients of the DSHS’ Developmental Disabilities Administration .............................................................................................................47 Office visit related to acamprosate, naltrexone, buprenorphine/naloxone ........................48 Aged, Blind, or Disabled (ABD) Evaluation Services ............................................................49 Behavior change intervention - smoking cessation .................................................................49 Services available...............................................................................................................49 Washington State Tobacco Quitline ..................................................................................50 Client eligibility .................................................................................................................50 Payment for a smoking cessation referral ..........................................................................51 Smoking cessation referral for an evaluation for a smoking cessation prescription..........52 Tobacco cessation for pregnant clients ..............................................................................52 Children's primary health care .................................................................................................56 Consultations............................................................................................................................56 TB treatment services ........................................................................................................56 Critical care ..............................................................................................................................57 Billing for critical care .......................................................................................................57 Where is critical care performed? ......................................................................................58 What is covered? ................................................................................................................58 Domiciliary, rest home, or custodial care services ..................................................................59 Emergency department services ..............................................................................................59 Emergency physician-related services ...............................................................................59 Alert! 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Physician-Related Services/Health Care Professional Services Habilitative services .................................................................................................................60 Billing for habilitative services ..........................................................................................60 Home services ..........................................................................................................................61 Home evaluation and management ....................................................................................61 TB treatment services – performed by professional providers – in client’s home ............61 Hospital inpatient and observation care services .....................................................................61 Admission status ................................................................................................................61 Change in admission status ................................................................................................62 Payment..............................................................................................................................65 Other guidelines .................................................................................................................65 Inpatient neonatal and pediatric critical care ...........................................................................66 Neonatal intensive care unit (NICU)/Pediatric intensive care unit (PICU) .......................66 Intensive (noncritical) low birth weight services (CPT codes 99478-99480) ..................68 Perinatal conditions ............................................................................................................68 Mental Health...........................................................................................................................69 Services provided to an MCO client during BHO-approved admissions ..........................69 Newborn care ...........................................................................................................................70 Does the agency pay for newborn screening tests? ...........................................................70 Physicals for clients of DSHS’ Developmental Disabilities Administration...........................71 Physician care plan oversight...................................................................................................71 Physician supervision of a patient requiring complex and multidisciplinary care modalities .....................................................................................................................72 Preventative medicine services ................................................................................................72 HIV/AIDS counseling/testing ............................................................................................72 Prolonged services ...................................................................................................................73 Prolonged services with direct patient contact...................................................................73 Physician standby services .................................................................................................74 Telemedicine ............................................................................................................................75 What is telemedicine? ........................................................................................................75 Who is eligible for telemedicine? ......................................................................................75 When does the agency cover telemedicine? ......................................................................76 Originating site (location of client) ....................................................................................76 Distant site (location of consultant) ...................................................................................77 Anesthesia .....................................................................................................................................78 General anesthesia ...................................................................................................................78 Regional anesthesia ..................................................................................................................80 Other ........................................................................................................................................80 Teaching anesthesiologists.......................................................................................................81 Physician fee schedule payment for services of teaching physicians ................................81 Anesthesia for dental................................................................................................................82 Anesthesia for maternity ..........................................................................................................82 Anesthesia for radiological procedures ....................................................................................83 Anesthesia payment calculation for services paid with base and time units ...........................83 Surgery ..........................................................................................................................................84 Alert! 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Physician-Related Services/Health Care Professional Services Smoking cessation ...................................................................................................................84 Pain management services .......................................................................................................84 Pain management procedure codes ....................................................................................84 Interoperative or postoperative pain management .............................................................88 Registered Nurse First Assistants ......................................................................................88 Billing/Payment .......................................................................................................................89 Bilateral procedures ...........................................................................................................89 Bundled services ................................................................................................................89 Global surgery payment .....................................................................................................91 Global surgery payment period ..........................................................................................92 Multiple surgeries ..............................................................................................................92 Other surgical policies .......................................................................................................93 Panniculectomy ..................................................................................................................95 How do providers get paid for implantable devices?...............................................................95 Pre-/intra-/postoperative payment splits ............................................................................96 Auditory system .......................................................................................................................96 Tympanostomies ................................................................................................................96 Cochlear implant services (clients age 20 and younger) ...................................................96 BAHA for clients age 20 and younger ...............................................................................97 Cardiovascular system .............................................................................................................98 Carotid Artery Stenting ......................................................................................................98 Vericose vein treatment .....................................................................................................98 Digestive system ......................................................................................................................99 Diagnostic upper endoscopy for GERD ............................................................................99 Closure of enterostomy ......................................................................................................99 Fecal microbiota therapy..................................................................................................100 Drug eluting stents .................................................................................................................100 Cardiovascular .......................................................................................................................100 Angioscopy ......................................................................................................................100 Apheresis..........................................................................................................................100 Transcatheter aortic valve replacement (TAVR) .............................................................101 Percutaneous pulmonary valve implantation (PPVI) .......................................................102 Female genital system ............................................................................................................103 Hysterectomies .................................................................................................................103 Sterilizations ....................................................................................................................103 Integumentary system ............................................................................................................104 Clarification of coverage policy for miscellaneous procedures .......................................104 Male genital system ...............................................................................................................104 Circumcisions ..................................................................................................................104 Musculoskeletal system .........................................................................................................105 Artificial disc replacement ...............................................................................................105 Bone growth stimulators ..................................................................................................105 Bone morphogenetic protein 2 for lumbar fusion ............................................................105 Bone morphogenetic protein 7 for lumbar fusion ............................................................106 Cervical spinal fusion arthrodesis ....................................................................................106 Cervical surgery for radiculopathy and myelopathy ........................................................106 Alert! 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Physician-Related Services/Health Care Professional Services Endoscopy procedures .....................................................................................................107 Epiphyseal ........................................................................................................................107 Hip resurfacing.................................................................................................................107 Hip surgery for femoroacetabular impingement syndrome .............................................107 Knee arthroscopy for osteoarthritis ..................................................................................108 Microprocessor-controlled lower limb prostheses ...........................................................108 Osteochondral allograft and autograft transplantation .....................................................109 Osteotomy reconstruction ................................................................................................109 Percutaneous kyphoplasty, vertebroplasty and sacroplasty .............................................110 Sacroiliac joint arthrodesis ...............................................................................................110 Robotic assisted surgery ..................................................................................................110 Nervous system ......................................................................................................................111 Discography .....................................................................................................................111 Facet neurotomy, cervical and lumbar .............................................................................111 Implantable infusion pumps or implantable drug delivery systems ................................112 Spinal cord stimulation for chronic neuropathic pain ......................................................112 Spinal injections for diagnostic or therapeutic purposes (outpatient) ..............................112 Transcutaneous electrical nerve stimulation (TENS) device ...........................................114 Sleep apnea ............................................................................................................................115 Surgical treatment for sleep apnea ...................................................................................115 Urinary systems .....................................................................................................................115 Collagen implants ............................................................................................................115 Indwelling catheter...........................................................................................................115 Urinary tract implants ......................................................................................................116 Urological procedures with sterilizations in the description............................................116 Radiology Services .....................................................................................................................117 Radiology services – general limits .......................................................................................117 Radiology modifiers for bilateral procedures ........................................................................117 Breast, Mammography...........................................................................................................117 Mammograms ..................................................................................................................117 Diagnostic Radiology (Diagnostic Imaging) .........................................................................118 Multiple procedure payment reduction (MPPR)..............................................................118 Which procedures require a medical necessity review by Qualis Health? ......................118 Imaging for rhinosinusitis ................................................................................................120 Computed tomography angiography (CTA) ....................................................................121 Contrast material ..............................................................................................................122 Consultation on X-ray examination .................................................................................122 Coronary artery calcium scoring ......................................................................................122 Magnetic resonance imaging (MRI) ................................................................................123 Portable X-rays ................................................................................................................123 Ultrasound screening for abdominal aortic aneurysm .....................................................124 Virtual colonoscopy or computed tomographic colonography ........................................124 Screening & Monitoring Tests for Osteopenia/Osteoporosis ..........................................124 Functional neuroimaging for primary degenerative dementia or mild cognitive impairment .................................................................................................................125 Alert! 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Physician-Related Services/Health Care Professional Services Diagnostic Ultrasound ...........................................................................................................125 Obstetrical ultrasounds.....................................................................................................125 Nuclear Medicine ...................................................................................................................126 Which procedures require a medical necessity review from the agency? .......................126 Which procedures require a medical necessity review by Qualis? ..................................126 Radiopharmaceutical diagnostic imaging agents .............................................................127 Nuclear medicine - billing ...............................................................................................127 Radiation Oncology ...............................................................................................................128 Intensity modulated radiation therapy (IMRT) ................................................................128 Proton beam radiation therapy .........................................................................................129 Stereotactic Radiation Surgery ..............................................................................................129 Stereotactic Body Radiation Therapy ....................................................................................129 Pathology and Laboratory ........................................................................................................130 Certifications ..........................................................................................................................130 Independent laboratories - certification ...........................................................................130 Reference labs and facilities - CLIA certification ...........................................................130 Anatomic Pathology...............................................................................................................130 Pap smears .......................................................................................................................130 Screening exams ....................................................................................................................131 Cancer screens .................................................................................................................131 Disease organ panels--automated multi-channel tests .....................................................132 Fetal fibronectin ...............................................................................................................133 Noninvasive prenatal diagnosis of fetal aneuploidy using cell-free fetal nucleic acids in maternal blood (NIPT)..................................................................................134 Vitamin D screening and testing ......................................................................................134 Drug Testing ..........................................................................................................................135 The agency pays for drug screens when both of the following apply: ............................135 Drug screening for medication assisted treatment (MAT) ..............................................136 Suboxone when used for pain control ..............................................................................140 Immunology ...........................................................................................................................140 HIV testing .......................................................................................................................140 Targeted TB testing with interferon-gamma release assays ............................................140 Molecular Pathology Tests ..............................................................................................141 Organ and disease-oriented panels.........................................................................................142 Automated multi-channel tests - payment .......................................................................142 Disease organ panel - nonautomated multi-channel ........................................................143 Billing ....................................................................................................................................144 Billing for laboratory services that exceed the lines allowed ..........................................144 Clinical laboratory codes .................................................................................................144 Coding and payment policies ...........................................................................................144 Laboratory physician interpretation procedure codes ......................................................146 Laboratory codes requiring modifier and PA clarification ..............................................146 Laboratory modifiers .......................................................................................................146 Laboratory services referred by CMHC or DBHR-contracted providers ........................147 STAT laboratory charges .................................................................................................148 Alert! 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Physician-Related Services/Health Care Professional Services Medicine ................................................................................................................................151 Allergen and clinical immunology.........................................................................................151 Allergen immunotherapy .................................................................................................151 Audiology ..............................................................................................................................152 Who is eligible to provide audiology services? ...............................................................152 What type of equipment must be used? ...........................................................................153 Audiology billing .............................................................................................................153 Audiology coverage table ................................................................................................153 Fee schedule .....................................................................................................................155 Cardiovascular .......................................................................................................................156 Catheter ablation ..............................................................................................................156 Heart catheterizations.......................................................................................................156 Outpatient cardiac rehabilitation ......................................................................................156 Central nervous system assessments/tests .............................................................................158 Coverage for developmental screening for delays and surveillance and screening for autism ...................................................................................................................158 Chemotherapy ........................................................................................................................159 Chemotherapy services ....................................................................................................159 Irrigation of venous access pump ....................................................................................160 Dialysis - End-Stage Renal Disease (ESRD) .........................................................................161 Inpatient visits for hemodialysis or outpatient non-ESRD dialysis services ...................161 Inpatient visits for dialysis procedures other than hemodialysis .....................................161 Endocrinology ........................................................................................................................162 Continuous glucose monitoring .......................................................................................162 Hydration, therapeutic, prophylactic, diagnostic injections, infusions ..................................162 Hydration therapy with chemotherapy.............................................................................162 Therapeutic or diagnostic injections/infusions ................................................................163 Concurrent infusion .........................................................................................................163 Immune Globulins, Serum, or Recombinant Products ..........................................................163 Hepatitis B (CPT code 90371) .........................................................................................163 Immune globulins ............................................................................................................164 Rabies immune globulin (RIG) ........................................................................................164 Medical genetics and genetic counseling services .................................................................165 Genetic counseling and genetic testing ............................................................................165 Prenatal genetic counseling..............................................................................................165 Applying to the agency to become a genetic counseling provider ..................................167 Miscellaneous ........................................................................................................................168 After-hours .......................................................................................................................168 Neurology and neuromuscular procedures ............................................................................168 Needle electromyography (EMGs) ..................................................................................168 Nerve conduction study (NCS) ........................................................................................169 Sleep medicine testing (sleep apnea) ...............................................................................169 Billing ..............................................................................................................................173 Sleep center physician consultations and referral for cognitive behavioral therapy (CBT) .........................................................................................................................174 Opthalmology – vision care services .....................................................................................174 Alert! 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Physician-Related Services/Health Care Professional Services Eye examinations and refraction services ........................................................................174 Coverage for additional examinations and refraction services ........................................175 Visual field exams............................................................................................................175 Vision therapy ..................................................................................................................175 Ocular prosthetics ............................................................................................................176 Eye surgery ......................................................................................................................176 Vision coverage table .......................................................................................................178 Manipulative therapy .............................................................................................................184 Other services and procedures ...............................................................................................185 Hyperbaric oxygen therapy ..............................................................................................185 Testosterone Testing ........................................................................................................186 Transcient Elastography...................................................................................................186 Psychiatry...............................................................................................................................186 Clozaril - case management .............................................................................................186 Pulmonary ..............................................................................................................................187 Ventilator management ....................................................................................................187 Special dermatological services .............................................................................................187 Ultraviolet phototherapy ..................................................................................................187 Special services ......................................................................................................................187 Group clinical visits for clients with diabetes or asthma .................................................187 Therapies (physical, occupational, and speech therapy) ........................................................189 Modifier required when billing ........................................................................................189 Vaccines/Toxoids (Immunizations) .......................................................................................190 Clients age 19 and older ...................................................................................................190 Herpes Zoster (Shingles) vaccine ....................................................................................191 Human papillomavirus (HPV) vaccine ............................................................................192 Injectable and nasal flu vaccines......................................................................................192 Maternity Care and Delivery ....................................................................................................193 Elective deliveries ..................................................................................................................193 Prenatal assessments not covered ..........................................................................................193 Confirmation of pregnancy ....................................................................................................194 Global (total) obstetrical (OB) care .......................................................................................194 Unbundling obstetrical care ...................................................................................................195 Antepartum care .....................................................................................................................196 Coding for antepartum care only ...........................................................................................197 Coding for deliveries..............................................................................................................197 Coding for postpartum care only ...........................................................................................198 Billing with modifiers ............................................................................................................199 Additional monitoring for high-risk conditions .....................................................................200 Labor management.................................................................................................................200 High-risk deliveries ................................................................................................................201 Consultations..........................................................................................................................202 General obstetrical payment policies and limitations ............................................................203 HIV/AIDS counseling/testing ................................................................................................204 Global (total) obstetrical (OB) care .......................................................................................204 Alert! 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Physician-Related Services/Health Care Professional Services Antepartum care only.............................................................................................................205 Deliveries ...............................................................................................................................205 Postpartum care only..............................................................................................................205 Additional monitoring for high-risk conditions .....................................................................206 Labor management.................................................................................................................206 High-risk deliveries ................................................................................................................206 Abortion services (drug induced)...........................................................................................207 Abortion center contracts (facility fees) ................................................................................207 Medical Supplies and Equipment .............................................................................................209 General payment policies .......................................................................................................209 Supplies included in an office call (bundled supplies) ..........................................................210 Alcohol and Substance Misuse Counseling.............................................................................213 What is included in SBIRT? ..................................................................................................213 What is covered? ....................................................................................................................214 SBIRT services will be covered by the agency when all of the following are met: ........214 Who is eligible to become a certified SBIRT provider? ........................................................215 What are the requirements to be a certified SBIRT provider?...............................................215 Required training .............................................................................................................215 What are the billing requirements for SBIRT services? ........................................................217 Who can bill for SBIRT services? .........................................................................................217 Alcohol and Substance Abuse Treatment Services .................................................................218 Medical services for clients in residential chemical dependency treatment ..........................218 Detoxification services...........................................................................................................218 Blood, blood products, and related services ............................................................................220 Payment for blood and blood products ..................................................................................220 Fee schedule ...........................................................................................................................226 Centers of Excellence .................................................................................................................227 List of approved Centers of Excellence (COEs) ....................................................................227 Services which must be performed in a COE ........................................................................227 Bariatric surgeries ............................................................................................................227 Hemophilia treatment COEs ............................................................................................228 Sleep studies.....................................................................................................................231 Transplants .......................................................................................................................232 Drugs Professionally Administered ..........................................................................................234 Invoice requirements ..............................................................................................................235 Drug pricing ...........................................................................................................................235 National drug code format .....................................................................................................235 Physicians billing for compound drugs..................................................................................236 Drugs requiring written/fax prior authorization .....................................................................237 Alert! 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Physician-Related Services/Health Care Professional Services Injectable drugs - limitations .................................................................................................237 Billing for injectable drugs and biologicals ...........................................................................238 Chemotherapy drugs ..............................................................................................................239 Billing for single-dose vials ...................................................................................................239 Billing for multi-dose vials ....................................................................................................240 Billing for oral anti-emetic drugs when part of a chemotherapy regimen .............................240 Rounding of units ...................................................................................................................241 Unlisted drugs ........................................................................................................................241 Botulinum toxin injections (Botox) .......................................................................................242 Collagenase injections ...........................................................................................................243 Hyaluronic acid/viscosupplementation ..................................................................................243 Alpha Hydroxyprogesterone (17P) ........................................................................................244 How to bill for Alpha Hydroxyprogesterone (17P) .........................................................245 Makena®................................................................................................................................245 Prolia/Xgeva ..........................................................................................................................245 Synagis® ................................................................................................................................246 What are the requirements for administration and authorization of Synagis®? ..............246 Are there other considerations when administering Synagis®? ......................................246 What are the authorization and billing procedures for Synagis®? ..................................247 What is the criteria for coverage or authorization of Synagis®? .....................................247 What are the authorization procedures for Synagis? ....................................................248 Verteporfin injection ..............................................................................................................249 Vivitrol ...................................................................................................................................250 Foot Care Services .....................................................................................................................251 Are foot care services covered? .............................................................................................251 What foot care services does the agency pay for? .................................................................251 Allowable conditions of the lower extremities by diagnosis .................................................253 What foot care services does the agency not pay for? ...........................................................253 May I bill the client for foot care services which the agency does not pay for? ...................254 How do I bill for foot care services? ......................................................................................254 Hospice ........................................................................................................................................256 Physicians providing service to hospice clients .....................................................................256 Concurrent care for children who are on hospice ..................................................................256 Concurrent/curative treatment .........................................................................................256 Services included under the agency’s concurrent/curative care benefit ..........................257 Authorization for concurrent/curative services ................................................................257 How do I request prior authorization or limitation extensions? ......................................257 Billing ..............................................................................................................................258 Major Trauma Services .............................................................................................................260 Increased payments for major trauma care ............................................................................260 Client eligibility groups included in TCF payments to physicians ........................................260 Client eligibility groups excluded from TCF payments to physicians ..................................261 Services excluded from TCF payments to physicians ...........................................................261 Alert! 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Physician-Related Services/Health Care Professional Services TCF payments to physicians ..................................................................................................261 Enhanced rates for trauma care ........................................................................................261 Criteria for TCF payments to physicians .........................................................................262 TCF payments to providers in transferred trauma cases ........................................................263 Billing for trauma care services .............................................................................................263 Adjusting trauma claims ........................................................................................................264 Injury severity score (ISS) .....................................................................................................264 Physician/clinical provider list ...............................................................................................266 Oral Health .................................................................................................................................267 Access to Baby and Child Dentistry (ABCD) Program.........................................................267 What is the purpose of the ABCD program? ...................................................................267 What dental services are billable by primary care medical providers? ...........................267 Training and certification .................................................................................................268 Dental disease prevention services ..................................................................................268 Oral Surgery ...........................................................................................................................269 Services performed by a physician or dentist specializing in oral maxillofacial surgery........................................................................................................................269 Provider requirements ......................................................................................................269 Oral surgery coverage table ...................................................................................................270 Prosthetic/Orthotics ...................................................................................................................279 Prosthetic & orthotics for podiatry and orthopedic surgeons ..........................................279 Supplies paid separately when dispensed from provider’s office/clinic ...............................280 Casting materials ..............................................................................................................280 Inhalation solutions ..........................................................................................................280 Metered dose inhalers and accessories ............................................................................280 Miscellaneous prosthetics & orthotics .............................................................................280 Miscellaneous Supplies ....................................................................................................281 Radiopharmaceutical diagnostic imaging agents .............................................................281 Urinary tract implants ......................................................................................................281 Transgender Health Services ....................................................................................................282 What transgender health services are covered? .....................................................................282 Fee-for-service clients ......................................................................................................283 Managed care clients........................................................................................................283 What are the components of transgender health services? ....................................................283 Who can provide gender dysphoria-related treatment? .........................................................288 Where can I download the attestation form? .........................................................................288 How do I become a COE provider? .......................................................................................289 Medical Necessity Review by Qualis Health ............................................................................290 What is a medical necessity review by Qualis Health? .........................................................290 Who can request a review? ....................................................................................................290 Alert! 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Physician-Related Services/Health Care Professional Services How do I register with Qualis Health? ..................................................................................291 Is authorization required for all Washington Apple Health (Medicaid) clients? ...................291 How do I submit a request to Qualis Health? ........................................................................292 What is the Qualis Health reference number for? ..................................................................292 When does the agency consider retroactive authorizations? .................................................293 What are the authorization requirements for advanced imaging? .........................................294 How does the agency’s hierarchy of evidence protocol apply? .............................................294 What are the authorization requirements for surgical procedures? .......................................295 Surgical Modifiers .................................................................................................................295 How does the agency’s hierarchy of evidence protocol apply? .............................................296 What criteria will Qualis Health use to establish medical necessity? ....................................296 Is there a provider appeals process for Qualis Health? ..........................................................296 Authorization..............................................................................................................................298 Prior authorization (PA) .........................................................................................................298 What is prior authorization (PA)? ....................................................................................298 How does the agency determine PA? ..............................................................................299 Services requiring PA ......................................................................................................300 Documentation requirements for PA or LE .....................................................................302 Written or fax prior authorization (PA) .................................................................................303 Limitation extension (LE) ......................................................................................................304 What is a limitation extension (LE)? ...............................................................................304 How do I request an LE authorization? ...........................................................................304 Expedited prior authorization (EPA) .....................................................................................305 What is expedited prior authorization (EPA)? .................................................................305 EPA guidelines.................................................................................................................306 EPA Criteria Coding List .................................................................................................306 Modifiers .....................................................................................................................................324 CPT/HCPCS ..........................................................................................................................324 Anesthesia ..............................................................................................................................329 Site-of-Service .............................................................................................................................331 Payment Differential ..................................................................................................................331 How are fees established for professional services performed in facility and nonfacility settings? .........................................................................................................331 How does the SOS payment policy affect provider payments? .............................................331 Does the agency pay providers differently for services performed in facility and nonfacility settings? .........................................................................................................332 When are professional services paid at the facility setting maximum allowable fee?...........332 When are professional services paid at the nonfacility setting maximum allowable fee? ...................................................................................................................................333 Which professional services have a SOS payment differential? ...........................................334 When are primary care providers paid at the Medicare rate? ................................................334 When are independent ARNPs eligible for a rate increase and which services apply? .........335 Alert! 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Physician-Related Services/Health Care Professional Services Fee Schedule Information .........................................................................................................336 Billing and Claim Form .............................................................................................................337 What are the general billing requirements? ...........................................................................337 Billing for multiple services.............................................................................................337 Billing for outpatient hospital services in hospital-based clinics.....................................337 How do I resolve issues with gender indicator when billing for transgender clients? ..........338 How do I complete the CMS-1500 claim form? ....................................................................340 Submitting professional services on a CMS-1500 claim form for Medicare crossovers ...................................................................................................................340 Utilization review...................................................................................................................341

Alert! This Table of Contents is automated. Click on a page number to go directly to the page.

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Important Changes to Apple Health Effective April 1, 2016 These changes are important to all providers because they may affect who will pay for services. Providers serving any Apple Health client should always check eligibility and confirm plan enrollment by asking to see the client’s Services Card and/or using the ProviderOne Managed Care Benefit Information Inquiry functionality (HIPAA transaction 270). The response (HIPAA transaction 271) will provide the current managed care organization (MCO), fee-for-service, and Behavioral Health Organization (BHO) information. A Provider FAQ is available online.

New MCO enrollment policy – earlier enrollment Beginning April 1, 2016, Washington Apple Health (Medicaid) implemented a new managed care enrollment policy placing clients into an agency-contracted MCO the same month they are determined eligible for managed care as a new or renewing client. This policy eliminates a person being placed temporarily in fee-for-service while they are waiting to be enrolled in an MCO or reconnected with a prior MCO. 

New clients are those initially applying for benefits or those with changes in their existing eligibility program that consequently make them eligible for Apple Health Managed Care.



Renewing clients are those who have been enrolled with an MCO but have had a break in enrollment and have subsequently renewed their eligibility.

Clients currently in fee-for-service or currently enrolled in an MCO are not affected by this change. Clients in fee-for-service who have a change in the program they are eligible for may be enrolled into Apple Health Managed Care depending on the program. In those cases, this enrollment policy will apply.

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How does this policy affect providers? 

Providers must check eligibility and know when a client is enrolled and with which MCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s Get Help Enrolling page.



MCOs have retroactive authorization and notification policies in place. The provider must know the MCO’s requirements and be compliant with the MCO’s new policies.

Behavioral Health Organization (BHO) The Department of Social and Health Services (DSHS) manages the contracts for behavioral health (mental health and substance use disorder (SUD)) services for nine of the Regional Service Areas (RSA) in the state, excluding Clark and Skamania counties in the Southwest Washington (SW WA) Region. BHOs will replace the Regional Support Networks (RSNs). Inpatient mental health services continue to be provided as described in the inpatient section of the Mental Health Provider guide. BHOs use the Access to Care Standards (ACS) for mental health conditions and American Society of Addiction Medicine (ASAM) criteria for SUD conditions to determine client’s appropriateness for this level of care.

Fully Integrated Managed Care (FIMC) Clark and Skamania Counties, also known as SW WA region, is the first region in Washington State to implement the FIMC system. This means that physical health services, all levels of mental health services, and drug and alcohol treatment are coordinated through one managed care plan. Neither the RSN nor the BHO will provide behavioral health services in these counties. Clients must choose to enroll in either Community Health Plan of Washington (CHPW) or Molina Healthcare of Washington (MHW). If they do not choose, they are auto-enrolled into one of the two plans. Each plan is responsible for providing integrated services that include inpatient and outpatient behavioral health services, including all SUD services, inpatient mental health and all levels of outpatient mental health services, as well as providing its own provider credentialing, prior authorization requirements and billing requirements. Beacon Health Options provides mental health crisis services to the entire population in Southwest Washington. This includes inpatient mental health services that fall under the Involuntary Treatment Act for individuals who are not eligible for or enrolled in Medicaid, and short-term substance use disorder (SUD) crisis services in the SW WA region. Within their available funding, Beacon has the discretion to provide outpatient or voluntary inpatient mental health services for individuals who are not eligible for Medicaid. Beacon Health Options is also 20

Physician-Related Services/Health Care Professional Services responsible for managing voluntary psychiatric inpatient hospital admissions for non-Medicaid clients. In the SW WA region some clients are not enrolled in CHPW or Molina for FIMC, but will remain in Apple Health fee-for-service managed by the agency. These clients include:        

Dual eligible – Medicare/Medicaid American Indian/Alaska Native (AI/AN) Medically needy Clients who have met their spenddown Noncitizen pregnant women Individuals in Institutions for Mental Diseases (IMD) Long-term care residents who are currently in fee-for-service Clients who have coverage with another carrier

Since there is no BHO (RSN) in these counties, Medicaid fee-for-service clients receive complex behavioral health services through the Behavioral Health Services Only (BHSO) program managed by MHW and CHPW in SW WA region. These clients choose from CHPW or MHW for behavioral health services offered with the BHSO or will be auto-enrolled into one of the two plans. A BHSO fact sheet is available online.

Apple Health Core Connections (AHCC) Coordinated Care of Washington (CCW) will provide all physical health care (medical) benefits, lower-intensity outpatient mental health benefits, and care coordination for all Washington State foster care enrollees. These clients include:   

Children and youth under the age of 21 who are in foster care Children and youth under the age of 21 who are receiving adoption support Young adults age 18 to 26 years old who age out of foster care on or after their 18th birthday

American Indian/Alaska Native (AI/AN) children will not be auto-enrolled, but may opt into CCW. All other eligible clients will be auto-enrolled.

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AHCC complex mental health and substance use disorder services AHCC clients who live in Skamania or Clark County receive complex behavioral health benefits through the Behavioral Health Services Only (BHSO) program in the SW WA region. These clients will choose between CHPW or MHW for behavioral health services, or they will be autoenrolled into one of the two plans. CHPW and MHW will use the BHO Access to Care Standards to support determining appropriate level of care, and whether the services should be provided by the BHSO program or CCW. AHCC clients who live outside Skamania or Clark County will receive complex mental health and substance use disorder services from the BHO and managed by DSHS.

Contact Information for Southwest Washington Beginning on April 1, 2016, there will not be an RSN/BHO in Clark and Skamania counties. Providers and clients must call the agency-contracted MCO for questions, or call Beacon Health Options for questions related to an individual who is not eligible for or enrolled in Medicaid. If a provider does not know which MCO a client is enrolled in, this information can located by looking up the patient assignment in ProviderOne. To contact Molina, Community Health Plan of Washington, or Beacon Health Options, please call: Molina Healthcare of Washington, Inc. 1-800-869-7165 Community Health Plan of Washington

1-866-418-1009

Beacon Health Options

Beacon Health Options 1-855-228-6502

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Definitions This section defines terms and abbreviations, including acronyms, used in this guide. Refer to the agency’s online Washington Apple Health Glossary for a more complete list of definitions. Acquisition cost (AC) – The cost of an item excluding shipping, handling, and any applicable taxes.

administration of fluids and/or blood incident to the anesthesia care, and interpretation of noninvasive monitoring by the anesthesiologist.

Acute care – Care provided for clients who are not medically stable or have not attained a satisfactory level of rehabilitation. These clients require frequent monitoring by a health care professional in order to maintain their health status.

Bundled services – Services integral to the major procedures that are included in the fee for the major procedure. Bundled services are not reimbursed separately.

Add-on procedure(s) – Secondary procedure(s) performed in addition to another procedure.

Code of federal regulations (CFR) – A codification of the general and permanent rules published in the federal register by the executive departments and agencies of the federal government.

Admitting diagnosis – The medical condition responsible for a hospital admission. [WAC 182-531-0050]

EPSDT provider – (1) A physician, advanced registered nurse practitioner (ARNP), or (2) a dentist, dental hygienist, audiologist, or optometrist who is an enrolled Medical Assistance provider and performs all or one component of the EPSDT screening.

Assignment – A process in which a doctor or supplier agrees to accept the Medicare program’s payment as payment in full, except for specific deductible and coinsurance amounts required of the patient.

HCPCS- See Healthcare Common Procedure Coding System.

BAHA – Auditory sound processors that allow wearers to hear by vibrating sound to the cochlea, or inner ear, by bone conduction. These sound processors are attached to a post implanted in the skull or held against the skull with a soft headband. Regardless of how these devices are held in position, they are considered BAHAs.

Healthcare Common Procedure Coding System (HCPCS) - Standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT® codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.

Base anesthesia units (BAU) – A number of anesthesia units assigned to an anesthesia procedure that includes the usual preoperative, intra-operative, and postoperative visits. This includes the

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Physician-Related Services/Health Care Professional Services 

Informed consent – Where an individual consents to a procedure after the provider who obtained a properly completed consent form has done all of the following:



(1) Disclosed and discussed the client’s diagnosis (2) Offered the client an opportunity to ask questions about the procedure and to request information in writing (3) Given the client a copy of the consent form (4) Communicated effectively using any language interpretation or special communication device necessary per 42 C.F.R. Chapter IV 441.257 (5) Given the client oral information about all of the following:





(a) The client’s right to not obtain the procedure, including potential risks, benefits, and the consequences of not obtaining the procedure (b) Alternatives to the procedure including potential risks, benefits, and consequences (c) The procedure itself, including potential risks, benefits, and consequences





Serve as advisors in communicating to the medical community the scope, limit, and purpose of the program. Assist in the development of agency medical policy, procedures, guidelines, and protocols. Evaluate the appropriateness and medical necessity of proposed or requested medical treatments in accordance with federal and state law, applicable regulations, agency policy, and community standards of medical care. Serve as advisors to agency staff, helping them to relate medical practice realities to activities such as claims processing, legislative requests, cost containment, and utilization management. Serve as liaisons between agency and various professional provider groups, health care systems (such as HMOs), and other state agencies. Serve as expert medical and program policy witnesses for agency at fair hearings.

Newborn or neonate or neonatal - A person younger than 29 days old. Noncovered service or charge – A service or charge not reimbursed by the agency.

Inpatient hospital admission – An admission to a hospital that is limited to medically necessary care based on an evaluation of the client using objective clinical indicators, assessment, monitoring, and therapeutic service required to best manage the client’s illness or injury, and that is documented in the client’s medical record.

Professional component – The part of a procedure or service that relies on the provider’s professional skill or training, or the part of that reimbursement that recognizes the provider’s cognitive skill. Relative value unit (RVU) – A unit that is based on the resources required to perform an individual service. RBRVS RVUs are comprised of three components – physician work, practice expense, and malpractice expense.

Medical consultant – Physicians employed by the agency who are authorities on the medical aspects of the Medical Assistance program. As part of their responsibilities, agency medical consultants:

24

Physician-Related Services/Health Care Professional Services Resource based relative value scale (RBRVS) – A scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved. RBRVS maximum allowable amount – The Medicare Fee Schedule relative value unit, multiplied by the statewide geographic practice cost index, times the applicable conversion factor. Revised code of Washington (RCW) – Washington State laws. Technical component – The part of a procedure or service that relates to the equipment set-up and technician’s time, or the part of the procedure and service reimbursement that recognizes the equipment cost and technician time.

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Introduction Acquisition cost Drugs with an acquisition cost (AC) indicator in the fee schedule with billed charges of $1,100.00 or greater, or supplies with billed charges of $50.00 or greater, require a manufacturer’s invoice in order to be paid. Attach the invoice to the claim, and if necessary, note the quantity given to the client in the Comments section of the claim form. DO NOT attach an invoice to the claim for procedure codes with an AC indicator in the fee schedule for drugs with billed charges under $1,100.00, or supplies with billed charges under $50.00, unless requested by the agency. Note: Bill the agency for one unit of service only when billing for drugs with an AC indicator.

Add-on codes The agency will not pay for procedure codes defined in the current CPT® manual as “add-on codes” when these codes are billed alone or with an invalid primary procedure code. Note: The agency has instituted claims edits requiring that “add-on” procedure codes be billed with a correct primary procedure.

By report Services with a by report (BR) indicator in the fee schedule with billed charges of $1,100.00 or greater require a detailed report in order to be paid. Attach the report to the claim. For billed charges under $1,100.00, DO NOT attach a report to the claim for services with a BR indicator in the fee schedule, unless requested by the agency.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Codes for unlisted procedures (CPT code XXX99) Providers must bill using the appropriate procedure code. The agency does not pay for procedures when they are judged to be less-than-effective (i.e., an experimental procedure), as reported in peer-reviewed literature (see WAC 182-501-0165). If providers bill for a procedure using a code for an unlisted procedure, it is the provider’s responsibility to know whether the procedure is effective, safe, and evidence-based. The agency requires this for all its programs, as outlined in WAC 182-501-0050. If a provider does not verify the agency’s coverage policy before performing a procedure, the agency may not pay for the procedure.

Conversion factors Conversion factors are multiplied by the relative value units (RVUs) to establish the rates in the agency’s Physician-Related Services/Health Care Professionals Fee Schedule. View the agency’s conversion factor table.

Diagnosis codes The agency requires valid and complete ICD diagnosis codes. When billing the agency, use the highest level of specificity (6th or 7th digits when applicable) or the services will be denied. The agency does not cover the following diagnosis codes when billed as the primary diagnosis:  

V00-Y99 codes (Supplementary Classification) Most codes in Z00-Z99 (factors influencing health status and contact with health services) The agency reimburses providers for only those covered procedure codes and diagnosis codes that are within their scope of practice.

Discontinued codes The agency follows Medicare and does not allow providers a 90-day grace period to use discontinued CPT and HCPCS codes. Use of discontinued codes to bill services provided after the date that the codes are discontinued will cause claims to be denied. CPT® codes and descriptions only are copyright 2015 American Medical Association

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National correct coding initiative The agency continues to follow the National Correct Coding Initiative (NCCI) policy. The Centers for Medicare and Medicaid Services (CMS) created this policy to promote national correct coding methods. NCCI assists the agency to control improper coding that may lead to inappropriate payment. The agency bases coding policies on the following:     

The American Medical Association’s (AMA) Current Procedural Terminology (CPT) manual National and local policies and edits Coding guidelines developed by national professional societies The analysis and review of standard medical and surgical practices Review of current coding practices

Procedure code selection must be consistent with the current CPT guidelines, introduction, and instructions on how to use the CPT coding book. Providers must comply with the coding guidelines that are within each section (e.g., E/M services, radiology, etc.) of the current CPT book. The agency may perform a post-pay review on any claim to ensure compliance with NCCI. NCCI rules are enforced by the ProviderOne payment system. Visit the NCCI on the web.

Procedure codes The agency uses the following types of procedure codes within this provider guide:   

Current Procedure Terminology (CPT) Level II Healthcare Common Procedure Coding System (HCPCS) Current Dental Terminology (CDT)

Procedures performed must match the description and guidelines from the most current CPT or HCPCS manual for all agency-covered services. Due to copyright restrictions, the agency publishes only the official short CPT descriptions. To view the full CPT description, refer to a current CPT manual.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Provider Eligibility Who may provide and bill for physician-related services? (WAC 182-531-0250 (1)) The following health care professionals may request enrollment with the agency to provide and bill for physician-related and health care professional services provided to eligible clients:                

Advanced Registered Nurse Practitioners (ARNPs) Federally Qualified Health Centers (FQHCs) Genetic Counselors Health Departments Hospitals currently licensed by the Department of Health (DOH) Independent (outside) laboratories CLIA-certified to perform tests. See WAC 182-531-0800 Licensed marriage and family therapists, only as provided in WAC 182-531-1400 Licensed mental health counselors, only as provided in WAC 182-531-1400 Licensed radiology facilities Licensed social workers, only as provided in WAC 182-531-1400 and 182-531-1600 Medicare-certified Ambulatory Surgery Centers (ASCs) Medicare-certified Rural Health Clinics (RHCs) Naturopathic physicians (see naturopathic physicians) Providers who have a signed agreement with the agency to provide screening services to eligible persons in the Early and Periodic, Screening, Diagnosis, and Treatment (EPSDT) program Registered Nurse First Assistants (RNFAs) Persons currently licensed by the State of Washington DOH to practice any of the following:     

Dentistry Medicine and osteopathy Nursing Optometry Podiatry

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Can naturopathic physicians provide and bill for physician-related services? Yes. Effective for dates of service on and after January 1, 2014, the agency added naturopathic physicians (taxonomy 175F00000X) to the list of professionals who can provide and bill for physician-related services. The agency recognizes a naturopathic physician’s scope of practice in accordance with RCW 18.36A.040. Licensure Naturopathic physicians with an active Washington State license may request enrollment with the agency. If a naturopathic physician is practicing naturopathic childbirth, the agency requires the naturopathic physician to have a separate active Washington State midwifery license. Limitations 

The agency does not pay for:  Nonsurgical cosmetic procedures.  Prescription or nonprescription botanical, herbal, or homeopathic medicine.



Manual manipulation - The agency applies the limitations for manual manipulation (mechanotherapy). See manipulative therapy (CPT® codes 98925-98929).



Malignancies – Treatment of a client with a malignancy must not be done independently by a naturopathic physician.



Controlled substance prescriptions – As authorized under WAC 246-836-211, these are limited to testosterone and codeine-containing substances in Schedules III-V.



Billing a client - A Medicaid client must not be charged for a covered over-the-counter (nonprescription) drug which is dispensed in the office. Covered over-the-counter drugs must be prescribed and the prescription filled by a pharmacy. Refer to the agency’s Prescription Drug Program Provider Guide for complete instructions and the agency’s Medicaid Covered Over the Counter Drug List.



Injectable drugs – Physician-administered injectable drugs are subject to prior authorization requirements as described in the agency’s Injectable Drugs Fee Schedule.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Can substitute physicians (locum tenens) provide and bill for physician-related services? Yes. Physicians may bill under certain circumstances for services provided on a temporary basis (i.e., locum tenens) to their patients by another physician [42 U.S.C. Chapter 7, Subchapter XIX, Sec 1396a (32)(C)]. The physician’s claim must identify the substituting physician providing the temporary services. Complete the claim as follows: 

Enter the NPI of the locum tenens physician who performed the substitute services on the HIPAA 837P transaction in the rendering provider field or field 24J on the CMS-1500 claim form (version 02/12).



Any provider that will perform as a locum tenens provider that will treat a Medicaid client must be enrolled as a Washington Apple Health (Medicaid) provider in order for claims to be paid. For enrollment information, go to New Providers.



Enter the billing provider information in the usual manner.



Use modifier Q6 when billing.

Documentation in the patient’s record must show that in the case of: 

An informal reciprocal arrangement, billing for temporary services was limited to a period of 14 continuous days, with at least one day elapsing between 14-day periods.



A locum tenens arrangement involving per diem or other fee-for-time compensation, billing for temporary services was limited to a period of 90 continuous days, with at least 30 days elapsing between 90-day periods.

Resident Physicians A resident cannot bill the agency for services they provide to a client. If a resident physician prescribes, orders, or refers, the resident physician must be enrolled with the agency as a nonbilling provider according to WAC 182-502-0006. If a resident is involved in any part of the patient care or treatment, the billing provider must use a GC modifier with the appropriate HCPCS or CPT code when billing. The modifier is for tracking purposes only and does not affect payment.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Which health care professionals does the agency not enroll? (WAC 182-531-0250 (2)) The agency does not enroll licensed or unlicensed health care practitioners not specifically listed in WAC 182-502-0002, including but not limited to:        

Acupuncturists Christian Science practitioners or theological healers Counselors (i.e., M.A. and M.S.N.), except as provided in WAC 182-531-1400 Herbalists Homeopathists Massage therapists as licensed by the Washington State Department of Health (DOH) Sanipractors Social workers, except those who have a master's degree in social work (MSW) and:   

Are employed by an FQHC. Who have received prior authorization from the agency to evaluate a client for bariatric surgery. As provided in WAC 182-531-1400.



Any other licensed or unlicensed practitioners not otherwise specifically provided for in WAC 182-502-0010



Any other licensed practitioners providing services that the practitioner is not licensed or trained to provide

The agency pays practitioners listed above for physician-related and health care professional services only if those services are mandated by, and provided to, clients who are eligible for one of the following:   

The EPSDT program A Medicaid program for qualified Medicare beneficiaries (QMB) A waiver program (WAC 182-531-0250 (3))

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Does the agency pay for out-of-state hospital admissions? (Does not include border hospitals) The agency pays for emergency care at an out-of-state hospital, not including hospitals in bordering cities, only for Medicaid and CHIP clients on an eligible program. See WAC 182-5010175 for recognized bordering cities. The agency requires prior authorization (PA) for elective, nonemergency care and approves these services only when both of the following apply:  

The client is on an eligible program (e.g., the Categorically Needy Program). The service is medically necessary and is unavailable in the State of Washington.

Providers requesting elective, out-of-state care must send a completed Out-of-State Medical Services Request form, 13-787, with additional required documentation attached, to the agency Medical Request Coordinator (see Resources Available). Providers must obtain prior authorization from the appropriate Behavioral Health and Service Integration Administration (BHSIA) designee for out-of-state psychiatric hospital admissions for all Washington Apple Health (Medicaid) clients. Neither the agency nor the BHSIA designee pays for inpatient services for non-Medicaid clients if those services are provided outside of the state of Washington. An exception is clients who are qualified for the medical care services (MCS) program. For these clients, the agency and the BHSIA designee pays for inpatient psychiatric services provided in bordering cities and critical border hospitals. All claims for admissions to out-of-state hospitals are paid as voluntary legal status as the Involuntary Treatment Act applies only within the borders of Washington State.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Client Eligibility How can I verify a patient’s eligibility? Providers must verify that a patient has Washington Apple Health coverage for the date of service, and that the client’s benefit package covers the applicable service. This helps prevent delivering a service the agency will not pay for. To verify eligibility, follow this two-step process: Step 1. Verify the patient’s eligibility for Washington Apple Health. For detailed instructions on verifying a patient’s eligibility for Washington Apple Health, see the Client Eligibility, Benefit Packages, and Coverage Limits section in the agency’s ProviderOne Billing and Resource Guide. If the patient is eligible for Washington Apple Health, proceed to Step 2. If the patient is not eligible, see the note box below. Step 2. Verify service coverage under the Washington Apple Health client’s benefit package. To determine if the requested service is a covered benefit under the Washington Apple Health client’s benefit package, see the agency’s Scope of Categories of Service Table.

Note: Patients who wish to apply for Washington Apple Health can do so in one of the following ways: 1.

By visiting the Washington Healthplanfinder’s website at: www.wahealthplanfinder.org

2.

By calling the Customer Support Center toll-free at: 855-WAFINDER (855-923-4633) or 855-627-9604 (TTY)

3.

By mailing the application to: Washington Healthplanfinder PO Box 946 Olympia, WA 98507

In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visit www.wahealthplanfinder.org or call the Customer Support Center.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Are clients enrolled in an agency-contracted managed care organization (MCO) eligible? Yes. Many agency clients are enrolled in one of the agency’s contracted managed care organizations (MCOs). For these clients, managed care enrollment will be displayed on the client benefit inquiry screen in ProviderOne. Clients enrolled in an agency-contracted MCO must obtain services through their MCO, unless otherwise noted. Note: A client’s enrollment can change monthly. Providers who are not contracted with the MCO must receive approval from both the MCO and the client’s primary care provider (PCP) prior to serving a managed care client. Send claims to the client’s MCO for payment. Call the client’s MCO to discuss payment prior to providing the service. Providers may bill clients only in very limited situations as described in WAC 182-502-0160.

Are clients enrolled in hospice eligible for services? Yes. The agency pays for hospice care for eligible clients. To be eligible, clients must be certified by a physician as terminally ill with a life expectancy of six months or less. Contact the local hospice agency and they will evaluate the client. Hospice will cover all services required for treatment of the terminal illness. These services must be provided by or through the hospice agency. See Hospice for additional information.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Coverage - General What is covered? (WAC 182-531-0100) The agency covers health care services, equipment, and supplies listed in this guide, according to agency rules and subject to the limitations and requirements in this guide, when they are: 

Within the scope of an eligible client's medical assistance program. Refer to WAC 182-501-0060 and 182-501-0065.



Medically necessary as defined in WAC 182-500-0070.

The agency evaluates a request for a service that is in a covered category under the provisions of WAC 182-501-0165. The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169. The agency covers the following physician-related services and health care professional services, subject to the conditions listed in this provider guide: 

Allergen immunotherapy services



Anesthesia services



Dialysis and end stage renal disease services (see the agency’s Kidney Center Services Provider Guide)



Emergency physician services



ENT (ear, nose, and throat) related services



Early and periodic screening, diagnosis, and treatment (EPSDT) services (see the agency’s Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Provider Guide)



Habilitative services (see Habilitative services)



Reproductive health services (see the agency’s Family Planning Provider Provider Guide) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Hospital inpatient services (see the agency’s Inpatient Hospital Provider Guide)



Maternity care, delivery, and newborn care services (see Maternity Care and Delivery)



Office visits



Vision-related services (see also the agency’s Vision Hardware for Clients 20 Years of Age and Younger Provider Guide)



Osteopathic treatment services



Pathology and laboratory services



Physiatry and other rehabilitation services



Foot care and podiatry services



Primary care services



Psychiatric services, provided by a psychiatrist



Psychotherapy services



Pulmonary and respiratory services



Radiology services



Surgical services



Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment



Other outpatient physician services

The agency covers physical examinations for medical assistance clients only when the physical examination is one or more of the following:   

A screening exam covered by the EPSDT program An annual exam for clients of the Developmental Disabilities Administration A screening pap smear performed according to nationally recognized clinical guidelines, mammogram, or prostate exam

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services By providing covered services to a client eligible for a medical assistance program, a provider who has signed an agreement with the agency accepts the agency's rules and fees as outlined in the agreement, which includes federal and state law and regulations, provider guides, and agency issuances.

Does the agency cover nonemergency services provided out-of-state? (WAC 182-501-0182) The agency covers nonemergency services provided out-of-state with prior authorization as described in WAC 182-501-0182. A designated bordering city is considered the same as an instate city for the purposes of health care coverage (see WAC 388-501-0175).

What services are noncovered? (WAC 182-501-0070)

General information Procedures that are noncovered are noted with (NC) in the Nonfacility Setting (NFS) and Facility Setting (FS) columns in the fee schedule. The agency reviews requests for noncovered health care services according to WAC 182-5010160 as an exception to rule (ETR). To request a noncovered service using the ETR process, send a completed Fax/Written Request Basic Information form, 13-756, to the agency (see Resources Available). Refer to the agency’s ProviderOne Billing and Resource Guide for information regarding noncovered services and billing an agency client who is on a fee-for-service program.

The following are examples of administrative costs and/or services not covered separately by the agency:        

Missed or canceled appointments Mileage Take-home drugs Educational supplies or services Copying expenses, reports, client charts, insurance forms Service charges/delinquent payment fees Telephoning for prescription refills Other areas as specified in this fee schedule CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

After-hours charges for services during regularly scheduled work hours

Noncovered physician-related and health care professional services (WAC 182-531-0150) The agency does not cover the following: 

Acupuncture, massage, or massage therapy



Any service specifically excluded by statute



Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation



Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to trauma, birth defect, or illness



Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC 182-501-0165



Hair transplantation



Marital counseling or sex therapy



More costly services when the agency determines that less costly, equally effective services are available



Vision-related services as follows:   

Services for cosmetic purposes only Group vision screening for eyeglasses Refractive surgery of any type that changes the eye's refractive error (refractive surgery is intended to reduce or eliminate the need for eyeglass or contact lens correction, and does not include intraocular lens implantation following cataract surgery)



Payment for body parts, including organs, tissues, bones and blood, except as allowed in this guide



Physician-supplied medication, except those drugs administered by the physician in the physician's office

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Physical examinations, routine checkups, and other preventive services, except as provided in this guide



Foot care to treat chronic acquired conditions of the foot such as, but not limited to:            

Treatment of mycotic disease tinea pedis Removal of warts, corns, or calluses Trimming of nails and other regular hygiene care Treatment of flat feet Treatment of high arches (cavus foot) Onychomycosis Bunions and tailor’s bunion (hallux valgus) Hallux malleus Equinus deformity of foot, acquired Cavovarus deformity, acquired Adult acquired flatfoot (metatarsus adductus or pes planus Hallux limitus



Except as provided in this guide, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services



Nonmedical equipment



Nonemergency admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas



Vaccines recommended or required for the sole purpose of international travel. This does not include routine vaccines administered according to current Centers for Disease Control (CDC) advisory committee on immunization practices (ACIP) immunization schedule for adults and children in the United States.

Note: The agency covers excluded services listed in this section if those services are mandated under and provided to a client who is eligible for one of the following:   

The EPSDT program A Medicaid program for qualified Medicare beneficiaries (QMBs) A waiver program

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Medical Policy Updates In accordance with WAC 182-501-0055, the agency has reviewed the recommendations of the Health Technology Assessment Clinical Committee (HTACC) (RCW 70.14.080 through 70.14.140) and has made the decision to adopt recommendations for the following technologies.

Policy updates effective 4/1/2016  

Tympanostomy tubes in children Imaging for Rhinosinusitis

Policy updates effective 10/1/2015  

Digital breast tomosynthesis (DBT) Sleep medicine testing (sleep apnea)

Policy updates effective 7/1/2015 

Testosterone testing

Policy updates effective 4/1/2015  

Screening and monitoring tests for osteopenia and osteoporosis Bilateral cochlear implants

Policy updates effective 1/1/2015     

Carotid artery stenting Facet neurotomy, cervical and lumber Proton beam radiation therapy Stereotactic radiation surgery Stereotactic body radiation therapy CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

For additional details and medical necessity criteria, see Health Technology Assessment Findings.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Evaluation and Management Evaluation and management documentation and billing The evaluation and management (E/M) service is based on key components listed in the CPT® manual. Providers must use either the 1995 or 1997 Documentation Guidelines for Evaluation & Management Services to determine the appropriate level of service. Once the licensed practitioner chooses either the 1995 or 1997 guidelines, the licensed practitioner must use the same guidelines for the entire visit. Chart notes must contain documentation that justifies the level of service billed. Documentation must:    

Be legible to be considered valid. Support the level of service billed. Support medical necessity for the diagnosis and service billed. Be authenticated by provider performing service with date and time.

Keys to documenting medical necessity to support E/M service:    

Document all diagnoses managed during the visit. For each established diagnosis, specify if the patient’s condition is stable, improved, worsening, etc. Document rationale for ordering diagnostic tests and procedures. Clearly describe management of the patient (e.g., prescription drugs, over the counter medication, surgery).

A provider must follow the CPT coding guidelines and their documentation must support the E&M level billed. While some of the text of CPT has been repeated in this provider guide, providers should refer to the CPT book for the complete descriptors for E/M services and instructions for selecting a level of service.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Advance directives/physician orders for lifesustaining treatment The agency covers for counseling and care planning services for end of life treatment when conducted by a licensed health care provider. End of life service should be evidence-based and utilize tested guidelines and protocols. This service may include assisting the client or the client’s authorized representative to understand and complete advance directives and/or a physician orders for life-sustaining treatment (POLST) form. The agency pays separately for this counseling and planning in addition to the appropriate E/M code. Bill for this service using one of the following procedure codes, as appropriate: Procedure Codes S0257 99497 99498

Short Descriptions End of life counseling Advncd care plan 30 min Advncd care plan addl 30 min

This service may include:   

Assessing client readiness Educating the client on their health status Helping the client choose a suitable surrogate and involving the designated surrogate in the conversation if appropriate  Discussing and clarifying values (e.g., “If you were in X situation, what would be most important to you?”)  Documenting the advance care plan with an advance directive and POLST if appropriate The Washington State Medical Association (WSMA) coordinates the Washington POLST Task Force with the Washington State Department of Health. The WSMA offers up-to-date POLST forms, frequently asked questions, and provides resources to providers and patients about the legality of and operational uses of POLST. For further information, see www.polst.org and www.wsma.org/polst.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Telephone services The agency pays for telephone services when used by a physician to report and bill for episodes of care initiated by an established patient (i.e., someone who has received a face-to-face service from you or another physician of the same specialty in your group in the past three years) or by the patient's guardian. Report and bill for telephone services using the following CPT codes: 

CPT code 99441 - Telephone evaluation and management (E/M) service provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion.



CPT code 99442 - Same as CPT code 99441 except call includes 11–20 minutes of medical discussion



CPT code 99443 - Same as CPT code 99441 except call includes 21–30 minutes of medical discussion.

Additional information when billing with these codes for telephone services: 1. Telephone services that are billed with CPT codes 99441, 99442 or 99443 must be personally performed by the physician. 2. If the telephone service relates to and takes place within the postoperative period of a procedure provided by the physician, the service is considered part of the procedure and should not be billed separately. 3. Telephone services should not be billed when the same services are billed as care plan oversight or anticoagulation management (CPT codes 99339-99340, 99374-99380 or 9936399364). 4. When a telephone service refers to an E/M service performed and billed by the physician within the previous seven days, it is not separately billable, regardless of whether it is the result of patient-initiated or physician-requested follow-up. 5. This service should not be billed if the service results in the patient being seen within 24 hours or the next available appointment.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Partnership Access Line The Partnership Access Line (PAL) is a telephone-based child mental health consultation system for Washington State. PAL employs child psychiatrists, child psychologists, and social workers affiliated with Seattle Children’s Hospital to deliver its consultation services. The PAL team is available to any primary care provider throughout Washington State. Washington’s primary care providers are encouraged to call the PAL toll free number 866-5997257 as often as they would like. PAL provides rapid consultation responses during business hours (Monday-Friday, 8:00 a.m. to 5:00 p.m.) for any type of child mental health issue that arises with any child. See also Primary Care Principles for Child Mental Health, by Robert Hilt, MD, Program Director, Partnership Access Line, Seattle Children’s Hospital.

Office and other outpatient services (WAC 182-531-0950)

Office or other outpatient visit limits The agency allows one office or other outpatient visit per noninstitutionalized client, per day for an individual provider (except for call-backs to the emergency room). Refer to WAC 182-5310500. Certain procedures are included in the office call and cannot be billed separately. Example: The agency does not pay separately for ventilation management (CPT codes 94002-94004, 94660, and 94662) when billed in addition to an Evaluation and Management (E/M) service, even if the E/M service is billed with modifier 25.

New patient visits The agency pays one new patient visit, per client, per provider or group practice in a three-year period. Note: A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient has received professional services from the physician or another physician in the same group and the same specialty within the prior three years.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Established patient visits (CPT code 99211) When billing the agency for CPT code 99211, at a minimum, the client’s record must be noted with the reason for the visit and the outcome of the visit. The note must be signed and dated (with title) by the qualified health care professional who provided the service.

Nursing facility services The agency allows two physician visits per month for a client residing in a nursing facility or an intermediate care facility. Nursing facility discharges (CPT codes 99315 and 99316) are not included in the two-visit limitation. The agency pays for one nursing facility discharge per client, per stay. Note: The two physician visits per month limit does not apply to pulmonologists or their designee that are seeing clients who are ventilator and/or tracheostomy dependent and residing in the respiratory care unit of a designated ventilator weaning nursing facility. For these clients, the physician visit limit is five per month.

Pre-operative visit prior to performing a dental service under anesthesia The agency allows one pre-operative evaluation and management (E/M) visit by a physician per client prior to performing a dental service under anesthesia. Bill using the appropriate dental diagnosis codes as the primary diagnosis along with the appropriate pre-op diagnosis codes as the secondary diagnosis. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals. For clients assigned to an agency managed care organization, bill the agency directly for E/Ms for dental surgery (not oral surgery).

Physical examination - clients of the DSHS’ Developmental Disabilities Administration The agency allows one physical examination per client, per 12 months for clients of DSHS’ Developmental Disabilities Administration (DDA) as identified in ProviderOne. Use HCPCS code T1023 with modifier HI and ICD diagnosis code Z13.4 or Z13.89 to bill for an examination.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Office visit related to acamprosate, naltrexone, buprenorphine/naloxone The agency will cover medication assisted treatment (MAT) products for the treatment of substance use disorders as an office-based therapy. The pharmacy will continue to require prior authorization for some medications. For coverage details see the pharmacy page. The agency pays for office visits related to acamprosate (Campral®), naltrexone (ReVia®), naltrexone (Vivitrol®) or buprenorphine. Buprenorphine/naloxone (Suboxone®): The agency pays for office visits related to buprenorphine/naloxone (Suboxone®). Clients enrolled in an agency-contracted managed care organization (MCO) must contact their MCO for information regarding their coverage. Acamprosate and oral naltrexone when prescribed as MAT are covered without prior authorization. Coverage for naltrexone injections The agency will cover, with prior authorization, naltrexone (vivitrol®) injections for clients who have a diagnosis of moderate to severe opioid or alcohol use disorder. Clients must have abstained from alcohol for four days prior to initiation of treatment. For treatment, clients must do all of the following: 

Must not be using opioid narcotics concurrently with naltrexone injections due to the potential to cause immediate and severe withdrawal



Be receiving adequate psychosocial support for substance use disorder either directly from the prescriber or as determined by the prescriber with available resources

Each injection is given no sooner than every four weeks. Treatment is limited to 6 doses in 24 weeks. Limitation extensions are determined on a case-by-case basis. See the pharmacy policy for additional information. Note: When requesting prior authorization, use the agency’s Medication Assisted Treatment Request for IM Naltrexone (HCA 13-331) form if a client requires medication-assisted treatment for less than six months. If a client requires medication assisted treatment beyond six months, the provider must complete the agency’s Medication Assisted Treatment (HCA 13-333) form and keep the completed form in the client’s file. This form must be completed for each additional six months of treatment.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Aged, Blind, or Disabled (ABD) Evaluation Services Effective for claims with dates of service on and after November 1, 2015, providers must be enrolled with ProviderOne to claim and receive payment for ABD Evaluation Services. See the Department of Social and Health Services’ (DSHS) Medical Evaluation and Diagnostic Procedures web page. Medical evidence reimbursements are solely for the cost of obtaining medical evidence of an impairment that limits work activity, and for the purposes of an ABD disability determination. See the DSHS Medical Evidence Reimbursement web page. For information regarding reimbursement for psychological evaluations and testing, see the DSHS Community Services Division (CSD) Mental Incapacity Evaluation Services web page.

Behavior change intervention - smoking cessation Smoking cessation, which can include free counseling, nicotine replacement therapy (NRT), and prescription drugs, represents a major advancement in public health for Washington State. Below is a brief overview of the way the benefit works and the services available for clients in the agency fee-for-service program. Clients enrolled in an agency-contracted managed care organization (MCO) must contact their MCO for information regarding the smoking cessation benefit.

Services available Refer clients to the toll-free Washington State Tobacco Quitline for one or more services, which include:   

Telephone counseling and follow-up support calls through the Quitline. Nicotine replacement therapy to include patches, lozenges, inhalers, nasal spray, or gum through the Quitline, if appropriate. Prescription medications recommended by the Quitline. The client will then be referred back to the provider for a prescription, if appropriate.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Washington State Tobacco Quitline 800-QUIT-NOW (1-800-784-8669)

English

855-DEJELO-YA (1-855-335-3569)

Spanish

1-877-777-6534

TTY Line & Video Relay

Client eligibility 

All Washington Apple Health (Medicaid) clients 18 years of age and older and all pregnant women regardless of age are eligible for smoking cessation services through the Tobacco Quitline.



Clients eligible for the Alien Emergency Medical (AEM) program or enrolled in the Family Planning Only or TAKE CHARGE programs are eligible for some of the above mentioned services; however, these clients are not eligible for prescription drugs and smoking cessation services provided by their primary care provider. These clients qualify for smoking cessation services provided by the Department of Health Tobacco Quitline. Visit www.quitline.com for current coverage.

When a client is receiving counseling from the Tobacco Quitline, the Tobacco Quitline may recommend a smoking cessation prescription for the client. The Tobacco Quitline will mail a letter to the client’s home with prescribing information for the client’s primary care provider. The client should take the letter to their primary care provider’s office for completion. The primary care provider will fax the letter and prescription to the agency at (360) 725-1754 for prior authorization. Over-the-counter nicotine replacement therapy (NRT) products will be supplied to the client directly from the Tobacco Quitline.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Payment for a smoking cessation referral The agency will pay a provider which may include physicians, advanced registered nurse practitioners (ARNPs), physician assistants (PAs), dentists, and dental hygienists for a smoking cessation referral (T1016) when all of the following are met: 

The client is pregnant or 18 years of age and older.



The client presents a Services Card and is covered by a Benefit Services Package.



The client is not eligible for the AEM program or enrolled in the Family Planning Only or TAKE CHARGE program.



The referral is billed with the appropriate ICD diagnosis. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

Bill using the procedure code T1016 if no other services are provided or billed. This service may be provided in combination with, but not reimbursed in addition to, another service or evaluation management office visit within the provider’s scope of practice.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Smoking cessation referral for an evaluation for a smoking cessation prescription The agency pays the prescriber for a smoking cessation referral (T1016) for an evaluation for a smoking cessation prescription when all of the following are met: 

The client is pregnant or 18 years of age or older.



The client is enrolled in this smoking cessation program.



The client presents a Services Card and is covered by a Benefit Package.



The client is not eligible for the AEM program or enrolled in the Family Planning Only or TAKE CHARGE program.



The referral is billed with the appropriate ICD diagnosis codes. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.



Evaluate the client for a smoking cessation prescription, with or without the client present, complete the form, and fax it to the agency’s Pharmacy Authorization Section, Drug Use and Review.



The referral is not billed in combination with an evaluation and management office visit.

Additional information:   

Call the agency toll-free at 800-562-3022. Visit Washington State Department of Health’s Tobacco Quitline. Visit Smoke Free Washington.

Tobacco cessation for pregnant clients The agency pays for face-to-face counseling for tobacco cessation for pregnant clients. Tobacco cessation counseling complements the use of prescription and nonprescription smoking cessation products. These products are also covered by Medicaid. Pregnant clients can receive provider-prescribed nicotine replacement therapy directly from a pharmacy and can obtain prescription medications for tobacco cessation without going through the Quitline. Clients must be actively receiving counseling services from their prescribing provider. The prescribing provider must add narrative to the prescription supporting that the prescriber is providing counseling. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Face-to-face visit requirements for pregnant women The Clinical Practice Guideline, Treating Tobacco Use and Dependence: 2008 Update demonstrated that efficacious treatments for tobacco users exist and should become a part of standard caregiving. Two components of counseling are especially effective, and clinicians are expected to use these when counseling pregnant patients making a quit attempt:  

Practical counseling (problem solving/skills training) Social support delivered as part of treatment

The guideline recommends that a practitioner should follow the "5 A's" of treating tobacco dependence, which include: Ask, Advise, Assess, Assist, and Arrange follow-up. For patients not ready to make a quit attempt, clinicians should use a brief intervention designed to promote the motivation to quit. Content areas that should be addressed can be captured by the “5 R’s”: Relevance, Risks, Rewards, Roadblocks, and Repetition. Research suggests that the “5 R’s” enhance future quit attempts. Providers must document the client’s pregnancy status and estimated date of confinement in the medical record. Additionally, the provider must establish and document the client’s motivation to quit tobacco use and provide an appropriate intervention based on client’s readiness to change. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in the guideline to be effective in increasing future quit attempts. For each visit, the provider needs to document the time and interventions used aimed at tobacco cessation.

Promotion of the motivation to quit for pregnant women All patients entering a health care setting should have their tobacco use status assessed routinely. Clinicians should advise all tobacco users to quit and then assess a patient's willingness to make a quit attempt. For patients not ready to make a quit attempt at the time, clinicians should use a brief intervention designed to promote the motivation to quit. Patients unwilling to make a quit attempt during a visit may lack information about the harmful effects of tobacco use and the benefits of quitting, may lack the required financial resources, may have fears or concerns about quitting, or may be demoralized because of previous relapse. Such patients may respond to brief motivational interventions that are based on principles of Motivational Interviewing (MI), a directive, patient-centered counseling intervention. There is evidence that MI is effective in increasing future quit attempts; however, it is unclear that MI is successful in boosting abstinence among individuals motivated to quit smoking.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Clinicians employing MI techniques focus on exploring a tobacco user's feelings, beliefs, ideas, and values regarding tobacco use in an effort to uncover any ambivalence about using tobacco. Once ambivalence is uncovered, the clinician selectively elicits, supports, and strengthens the patient's “change talk” (e.g., reasons, ideas, needs for eliminating tobacco use) and “commitment language” (e.g., intentions to take action to change smoking behavior, such as not smoking in the home). MI researchers have found that having patients use their own words to commit to change is more effective than clinician exhortations, lectures, or arguments for quitting, which tend to increase rather than lessen patient resistance to change. The four general principles that underlie MI are: (1) express empathy, (2) develop discrepancy, (3) roll with resistance, and (4) support self-efficacy. Specific MI counseling strategies that are based on these principles are listed in Strategy B1. Because this is a specialized technique, it may be beneficial to have a member of the clinical staff receive training in motivational interviewing. The content areas that should be addressed in a motivational counseling intervention can be captured by the “5 R's”: relevance, risks, rewards, roadblocks, and repetition (Strategy B2). Research suggests that the “5 R's” enhance future quit attempts. Providers must provide client educational materials on the benefits of not using tobacco products and document this in the client’s record.

Provider types for providing face-to-face smoking cessation counseling for pregnant women Office-based practitioners (physicians, registered nurse practitioners, Physician-AssistantsCertified), Psychologists, Pharmacists, and Licensed Midwives (LM).

Benefit limitations for providing face-to-face smoking cessation counseling for pregnant women A cessation counseling attempt occurs when a qualified physician or other Medicaid-recognized practitioner determines that a beneficiary meets the eligibility requirements and initiates treatment with a cessation counseling attempt. Face-to-face cessation counseling attempts are defined and limited as follows:  

An attempt is defined as up to four cessation counseling sessions. Two cessation counseling attempts (or up to 8 sessions) are allowed every 12 months.

This limit applies to the client regardless of the number of providers a client may see for tobacco cessation. Providers can request a limitation extension by submitting a request to the agency. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Documentation requirements Keep patient record information on file for each Medicaid patient for whom a smoking and tobacco-use cessation counseling claim is made. Medical record documentation must include standard information along with sufficient patient history to adequately demonstrate that Medicaid coverage conditions were met. Documentation must include the client’s EDC Diagnosis codes should reflect that the client is pregnant and has a tobacco use disorder such as diagnosis codes O99.330 – O99.335. Also include if the condition the patient is being treated for with a therapeutic agent whose metabolism or dosing is affected by tobacco use.

Billing codes Procedure Code 99407

Short Description Behav chng smoking > 10 min (for pregnant clients only)

Comments Pregnant clients are eligible for two quit attempts annually. Limited to one counseling session per day.

Provider resources AHRQ's Treating Tobacco Use and Dependence: 2008 Update– This site provides the DHHS Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence: 2008 Update (PHSG) and includes evidence-based treatment, provider and patient educational materials. Helping Smokers Quit – A Guide for Clinicians The National Partnership to Help Pregnant Smokers Quit

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Children's primary health care (CPT codes 99201-99215) 

The agency pays a higher payment rate for primary health care performed in the office setting (CPT codes 99201-99215) for children age 20 and younger. These are the only services that are paid at the higher rate.



If a child is younger than 60 days of age and has not been issued an individual ProviderOne Client ID, use the mother's ProviderOne Client ID, and put "SCI=B" in the claim notes field. Put the child’s name, gender, and birth date in the client information fields. If the mother is enrolled in an agency-approved managed care organization (MCO), newborns will be enrolled in the same MCO as their mother.

Consultations TB treatment services Performed by professional providers – office visits only The E/M codes 99201-99215 are for office visits only, and must be billed for professional providers such as physicians (or nursing staff under a physician’s supervision), Advanced Registered Nurse Practitioners (ARNPs), and Physician Assistants (PAs). Performed by professional providers – in client’s home, see E/M home services. Performed by nonprofessional providers – office visits and in client’s home Health departments billing for TB treatment services provided by nonprofessional providers in either the client’s home or in the office must bill using HCPCS code T1020 (personal care services). Do not bill the initial visit with a modifier. Follow-up visits must be billed using T1020 with modifier TS (follow-up services modifier). Use the appropriate ICD diagnosis code. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Critical care (CPT codes 99291-99292) (WAC 182-531-0450) Note: For neonatal or pediatric critical care services, see Neonatal Intensive Care Unit (NICU)/Pediatric Intensive Care Unit (PICU). Critical care is the direct delivery and constant attention by a provider(s) for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s); to treat single or multiple vital organ system failure; and/or to prevent further life threatening deterioration of the patient’s condition. Providing medical care to a critically ill, injured, or postoperative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements. Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility. Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.

Billing for critical care When billing for critical care, providers must bill using CPT codes 99291-99292: 

For the provider’s attendance during the transport of critically ill or critically injured clients age 25 months or older to or from a facility or hospital.



To report critical care services provided in an outpatient setting (e.g., emergency department or office), for neonates and pediatric clients up through 24 months.



To report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured client, even if the time spent by the physician on that date is not continuous. For any given period of time spent providing critical care services, the physician must devote his or her full attention to the client and cannot provide services to any other patient during the same period of time. Note: Surgery, stand-by, or lengthy consultation on a stable client does not qualify as critical care.

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Physician-Related Services/Health Care Professional Services

Where is critical care performed? Critical care is usually performed in a critical care area of a hospital, such as a(n):    

Coronary care unit. Intensive care unit. Respiratory care unit. Emergency care facility.

What is covered? The agency covers: 

A maximum of three hours of critical care per client, per day.



Critical care provided by the attending physician who assume(s) responsibility for the care of a client during a life-threatening episode.



Critical care services provided by more than one physician if the services involve multiple organ systems (unrelated diagnosis). However, in the emergency room, payment for critical care services is limited to one physician.

The following services (with their corresponding CPT codes) are included in critical care. Do not bill these separately:        

Vascular access procedures (CPT codes 36000, 36410, 36415, 36591, and 36600) Gastric intubation (CPT codes 43752 and 43753) Chest X-rays (CPT codes 71010, 71015, and 71020) Temporary transcutaneous pacing (CPT codes 92953) The interpretation of cardiac output measurements (CPT codes 93561-93562) Ventilator management (CPT codes 94002-94004, 94660, and 94662) Pulse oximetry (CPT codes 94760 and 94762) Blood gases, and information data stored in computers (e.g., ECGs, blood pressures, hematologic data) (CPT code 99090) Note: CPT code 43752 may be billed separately when it is the only procedure code billed.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Domiciliary, rest home, or custodial care services CPT codes 99304-99318 are not appropriate E/M codes for use in place of service 13 (Assisted Living) or 14 (Group Home). Providers must use CPT codes 99324-99328 or 99334-99337 for E/M services provided to clients in these settings.

Emergency department services Emergency physician-related services (CPT codes 99281-99285) (WAC 182-531-0500) 

For services performed by the physician assigned to, or on call to, the emergency department, bill the agency using CPT codes 99281-99285. Note: For multiple emergency room (ER) visits on the same day with related diagnoses, the time(s) of the additional visit(s) must be noted in the Comments field of the claim form.



The agency does not pay emergency room physicians for hospital admissions (e.g., CPT codes 99221-99223) or after-hours services (e.g., CPT codes 99050 and 99053).



Physicians who perform emergency room services must not bill modifier 54 when billing the agency for surgical procedures.



Physicians who provide only the follow-up services for minor procedures performed in emergency departments must bill the appropriate level of office visit code without modifier 55.



The agency follows Medicare’s policy to not pay emergency room providers for the following procedure codes: CPT codes 96360-96361 or 96365-96368.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Habilitative services Habilitative services are those medically necessary services provided to help a client partially or fully attain or maintain developmental age-appropriate skills that were not fully acquired due to a congenital, genetic, or early-acquired health condition. Such services are required to maximize the client’s ability to function in his or her environment. For those clients in the expanded population and covered by the Alternative Benefit Plan (ABP) only, the agency covers prosthetic and orthotic (P&O) devices and supplies, durable medical equipment (DME) devices and supplies, and outpatient therapy (physical, occupational, and speech) to treat one of the qualifying conditions listed in the agency’s Habilitative Services Provider Guide, under Client Eligibility.

Billing for habilitative services Habilitative services must be billed using one of the qualifying diagnosis codes listed in the agency’s Habilitative Services Provider Guide in the primary diagnosis field on the claim form. Neurodevelopmental Centers, Outpatient Hospital Services, Physician-Related Services/Health Care Professional Services (includes Audiology), Home Health Services, and Outpatient Rehabilitation providers who provide physical therapy, occupational therapy, or speech language pathology to treat a condition that qualifies for habilitative services, for a client enrolled in ABP, must bill for these therapies according to the agency’s Habilitative Services Provider Guide. Services and equipment related to any of the following programs must be billed using their specific provider guide:   

Wheelchairs, Durable Medical Equipment, and Supplies Prosthetic/Orthotic Devices and Supplies Complex Rehabilitative Services

All other program requirements are applicable to a habilitative service and should be followed unless otherwise directed (e.g., prior authorization).

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Home services Home evaluation and management The agency pays for home evaluation and management (CPT codes 99341-99350) only when services are provided in place of service 12 (home).

TB treatment services – performed by professional providers – in client’s home When billing for TB treatment services provided by professional providers in the client’s home, Health Departments may also bill CPT codes 99341 and 99347. For TB treatment services performed by nonprofessional providers in client’s home, see TB treatment services for nonprofessional providers – office or client’s home.

Hospital inpatient and observation care services (CPT codes 99217-99239) (WAC 182-531-0750) Inpatient admissions must meet intensity of service/severity of illness criteria for an acute inpatient level of care. Admission status changes must be noted in the client’s chart.

Admission status Admission status is a client’s level of care at the time of admission. Some examples of typical types of admission status are: inpatient, outpatient observation, medical observation, outpatient surgery or short-stay surgery, or outpatient (e.g., emergency room). Admission status is determined by the admitting physician or practitioner. Continuous monitoring, such as telemetry, can be provided in an observation or inpatient status; consider overall severity of illness and intensity of service in determining admission status rather than any single or specific intervention. Specialty inpatient areas (including intensive care unit or critical care unit)) can be used to provide observation services. Level of care, not physical location of the bed, dictates admission status.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Change in admission status A change in admission status is required when a client’s symptoms/condition and/or treatment does not meet medical necessity criteria for the level of care the client is initially admitted to. The documentation in the client’s medical record must support the admission status and the services billed. The agency does not pay for:   

Services that do not meet the medical necessity of the admission status ordered. Services that are not documented in the hospital medical record. Services greater than what is ordered by the physician or practitioner responsible for the client’s hospital care.

Inpatient to outpatient observation The attending physician or practitioner may make an admission status change from inpatient to outpatient observation when: 

The attending physician/practitioner and/or the hospital’s utilization review staff determine that an inpatient client’s symptoms/condition and treatment do not meet medical necessity criteria for an acute inpatient level of care and do meet medical necessity criteria for an observation level of care.



The admission status change is made prior to, or on the next business day following, discharge.



The admission status change is documented in the client’s medical record by the attending physician or practitioner. If the admission status change is made following discharge, the document must: 

Be dated with the date of the change.



Contain the reason the change was not made prior to discharge (e.g., due to the discharge occurring on the weekend or a holiday).

Outpatient observation to inpatient The attending physician or practitioner may make an admission status change from outpatient observation to inpatient when: 

The attending physician/practitioner and/or the hospital’s utilization review staff determine that an outpatient observation client’s symptoms/condition and treatment meet medical necessity criteria for an acute inpatient level of care.

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Physician-Related Services/Health Care Professional Services 

The admission status change is made prior to, or on the next business day following, discharge.



The admission status change is documented in the client’s medical record by the attending physician or practitioner. If the admission status change is made following discharge, the documentation must: 

Be dated with the date of the change.



Contain the reason the change was not made prior to discharge (e.g., due to the discharge occurring on the weekend or a holiday).

Inpatient or outpatient observation to outpatient The attending physician or practitioner may make an admission status change from inpatient or outpatient observation to outpatient when: 

The attending physician/practitioner and/or the hospital’s utilization review staff determine that an outpatient observation or inpatient client’s symptoms/condition and treatment do not meet medical necessity criteria for observation or acute inpatient level of care.



The admission status change is made prior to, or on the next business day following, discharge.



The admission status change is documented in the client’s medical record by the attending physician or practitioner. If the admission status change is made following discharge, the documentation must: 

Be dated with the date of the change.



Contain the reason the change was not made prior to discharge (e.g., due to the discharge occurring on the weekend or a holiday).

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Outpatient surgery/procedure to outpatient observation or inpatient The attending physician or practitioner may make an admission status change from outpatient surgery/procedure to outpatient observation or inpatient when: 

The attending physician/practitioner and/or the hospital’s utilization review staff determine that the client’s symptoms/condition and/or treatment require an extended recovery time beyond the normal recovery time for the surgery/procedure and medical necessity for outpatient observation or inpatient level of care is met.



The admission status change is made prior to, or on the next business day following, discharge.



The admission status change is documented in the client’s medical record by the attending physician or practitioner. If the admission status change is made following discharge, the documentation must: 

Be dated with the date of the change.



Contain the reason the change was not made prior to discharge (e.g., due to the discharge occurring on the weekend or a holiday).

Note: During post-payment retrospective utilization review, the agency may determine the chronic care management is not supported by documentation in the medical record. The agency may consider payment made in this circumstance an overpayment and payment may be recouped or adjusted.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Payment The agency pays for: 

One inpatient hospital call per client, per day for the same or related diagnoses. The agency does not pay separately for the hospital call if it is included in the global surgery payment. (See Other Surgical Policies for information on global surgery policy.)



Professional inpatient services (CPT codes 99221-99223) during the global surgery follow-up period only if they are performed on an emergency basis and are unrelated to the original surgery. Use modifier 24 to indicate that the service is unrelated to the original surgery. Note: The agency pays providers for CPT codes 99221-99223 for scheduled hospital admissions during the follow-up period only when billed with a modifier 24.

The agency does not pay for: 

A hospital admission (CPT codes 99221-99223) and a planned surgery billed in combination. The hospital admission is included in the global fee for the surgery.



Inpatient or observation care services [including admission and discharge services (CPT codes 99234-99236) for stays of less than 8 hours on the same calendar date.

Other guidelines 

When a hospital admission (CPT codes 99221-99223) and an emergency surgery is billed in combination, the agency will pay when there is a decision to do surgery, the provider has not seen the client for this condition, and modifier 57 is used. This only applies to surgical procedures with a 90-day global period.



When a client is admitted for observation care for less than 8 hours and is discharged on the same calendar date, providers must bill using CPT codes 99218-99220. The agency does not pay providers separately for discharge services.



When a client is admitted for observation care and is discharged on a different calendar date, providers must bill using CPT codes 99218-99220 and observation discharge CPT code 99217.



When a client qualifies for an inpatient hospital admission and is discharged on a different calendar date, providers must bill using CPT codes 99221-99233 and hospital discharge day management CPT code 99238 or 99239. CPT® codes and descriptions only are copyright 2015 American Medical Association

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When a client qualifies for an inpatient hospital admission and is discharged on the same calendar date, providers must bill using CPT codes 99234-99236. The agency does not pay providers separately for hospital discharge day management services.



Providers must satisfy the documentation requirements for both admission to and discharge from, inpatient or observation care in order to bill CPT codes 99234-99236. The length of time for observation care or treatment status must also be documented.



When clients are fee-for-service (FFS) when admitted to a hospital and then enroll in an agency managed care organization (MCO) during the hospital stay, the entire stay for physician services is paid FFS until the client is discharged. Enter the initial hospitalization date in the appropriate field for the claim billing format. For billing details, see the ProviderOne Billing and Resource Guide.

Inpatient neonatal and pediatric critical care Neonatal intensive care unit (NICU)/Pediatric intensive care unit (PICU) (CPT codes 99468-99480) (WAC 182-531-0900) NICU/PICU care includes management, monitoring, and treatment of the neonate/infant including respiratory, pharmacological control of the circulatory system, enteral and parenteral nutrition, metabolic and hematological maintenance, parent/family counseling, case management services, and personal direct supervision of the health care team’s activities. The agency covers: 

One NICU/PICU service per client, per day.



Intensive observation, frequent interventions, and other intensive services for neonates. Use CPT code 99477 for initial hospital care, per day, when a neonate requires intensive observation, frequent interventions and other intensive services. Providers may report CPT 99460 and 99477 when two distinct services are provided on the same day, but must use modifier 25 with CPT code 99460. Bill CPT code 99460 with modifier 25 when a normal newborn is seen after an uneventful delivery and then later the infant develops complications and is transferred to an intensive setting for observation, frequent interventions, and other intensive services.



NICU/PICU services when directing the care of a neonate/infant in a NICU/PICU. These codes represent care beginning with the date of admission to the NICU/PICU. Note: Once the infant is no longer considered critically ill, hospital care CPT codes 99231-99233 (>2500 grams) or 99478-99480 (<2500 grams) must be used. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Newborn resuscitation (CPT code 99464, 99465) in addition to NICU/PICU services.



The provider’s attendance during the transport of critically ill or critically injured pediatric clients 24 months of age or younger to or from a facility or hospital (CPT code 99466 or 99467).



CPT codes 99291-99292 for critical care services provided in an outpatient setting when the client is 24 months of age or younger.

The following services and the subsequent intensive, noncritical services (with their corresponding CPT codes) are included in neonatal or pediatric critical care. Do not bill these separately. Providers must follow the national CCI edits as this list is not exhaustive:



Bladder catheterization (CPT codes 51701- 51702)



Central (CPT code 36555) or peripheral vessel catheterization (CPT code 36000)



Continuous positive airway pressure (CPAP) (CPT code 94660)



Endotracheal intubation (CPT code 31500)



Initiation and management of mechanical ventilation (CPT codes 94002-94004)



Invasive or noninvasive electronic monitoring of vital signs, bedside pulmonary function testing (CPT code 94375), and/or monitoring or interpretation of blood gases or oxygen saturation (CPT codes 94760-94762)



Lumbar puncture (CPT code 62270)



Oral or nasogastric tube placement (CPT code 43752)



Other arterial catheters (CPT codes 36140 and 36620)



Umbilical arterial catheterization (CPT code 36660)



Umbilical venous catheterization (CPT code 36510)



Suprapubic bladder aspiration (CPT code 51100)



Surfactant administration, intravascular fluid administration (CPT codes 96360, 96361, 90780, and 90781)



Transfusion of blood components (CPT codes 36430 and 36440) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Vascular punctures (CPT codes 36420 and 36600)



Vascular access procedures (CPT codes 36400, 36405, and 36406) Note: Procedure code 43752 may be billed separately when it is the only procedure code billed.

Intensive (noncritical) low birth weight services (CPT codes 99478-99480) 

Bill the appropriate procedure codes only once per day, per client.



These codes represent care that begins subsequent to the admission date.

Perinatal conditions The agency covers professional services related to conditions originating in the perinatal period if all of the following are met: 

The services are considered to be medically necessary and would otherwise be covered by the agency.



Professional services are provided in an inpatient hospital (place of service 21).



ICD diagnosis codes are listed as the primary diagnosis. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.



An admission date is included on the claim form.



There are 28 or fewer days between the patient’s date of birth and the admission date listed on the claim form.

For clients who transfer between facilities for services not otherwise available, or to a higher level of care, the original date of admission must be used on the claim form to represent a continuous episode of care. For clients greater than 28 days of age, the appropriate ICD diagnosis codes may be listed as the secondary rather than the primary diagnosis.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Mental Health For coverage and billing information for mental health services for children and adults, including evidence-based medicine, evidence-based practice, research-based practice, and evidence-based health care (collectively “EBM”), see the agency’s Mental Health Services Provider Guide.

Services provided to an MCO client during BHO-approved admissions How do I bill the professional mental health services for an inpatient MCO client? The agency pays for psychiatric services provided by a psychiatrist, psychologist, or psychiatric ARNP to an MCO client during the BHO-authorized admission. Expedited prior authorization is required. See EPA#870001369 for coverage criteria. If these services are provided by any other provider during a BHO-authorized admission, the services must be billed to the MCO.

How do I bill the professional services in the emergency room setting for the MCO client who will be transferred to another facility for a BHO admission? The agency pays for professional services provided in the emergency room to an MCO client with a psychiatric diagnosis (290.X-319.X) only when the visit results in a BHO-approved admission to a different hospital. All other ER visits must be billed directly to the client’s MCO. Expedited prior authorization is required. See EPA#870001370 for coverage criteria.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Newborn care (CPT 99460, 99461) To assist providers in billing CPT codes with "newborn" in the description, the agency defines a newborn as 28 days old or younger. Newborn diagnosis codes are to be used as the primary diagnosis during the newborn 28-day period. After 28 days and throughout the life of the patient, a newborn code may be used as an additional diagnosis if the condition is still present. The agency covers: 

One newborn evaluation per newborn when they are not discharged on the same day using either CPT code 99460 for hospital or birthing center or CPT code 99461 for home births.



Subsequent hospital care (other than initial evaluation or discharge) using CPT code 99462.



One newborn evaluation and discharge per newborn performed in the hospital or birthing center on the same day using CPT code 99463.

Does the agency pay for newborn screening tests? The midwife or physicians will collect the blood for the newborn screening and send it to the Washington State Department of Health (DOH). DOH will bill the agency for payment of HCPCS code S3620. The newborn screening panel includes:           

Biotinidase deficiency Congenital adrenal hyperplasia (CAH) Congenital hypothyroidism Homocystinuria Phenylketonuria (PKU) Galactosemisa Hemoglobinopathies Homocystinuria Maple Syrup Urine Disease (MSUD) Medium chain acyl-CoA dehydrogenase deficiency (MCAD deficiency) Severe combined immunodeficiency (SCID) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Note: Payment includes two tests for two different dates of service, allowed once per newborn. Do not bill HCPCS code S3620 if the baby is born in the hospital. This code is only for outpatient services in birthing centers, physician offices, and homes in which midwives provide home births. Note: The agency covers circumcisions (CPT codes 54150, 54160, and 54161) only with medical ICD diagnosis codes Phimosis, Balanoposthitis, or Balanitis Xerotica. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

Physicals for clients of DSHS’ Developmental Disabilities Administration The agency covers one physical every 12 months for clients of the Developmental Disabilities Administration (DDA) within the Department of Social and Health Services. Use HCPCS code T1023 with modifier HI and the appropriate ICD diagnosis code Z13.4 or Z13.89 to bill for an annual exam.

Physician care plan oversight (CPT codes 99375, 99378, and 99380) (WAC 182-531-1150) The agency covers: 

Physician care plan oversight services once per client, per month.  

A plan of care must be established by the home health agency, hospice, or nursing facility. The provider must perform 30 or more minutes of oversight services for the client each calendar month.

The agency does not cover: 

Physician care plan oversight services of less than 30 minutes per calendar month (CPT codes 99374, 99377, and 99379).



Physician care plan oversight services provided by more than one provider during the global surgery payment period, unless the care plan oversight is unrelated to the surgery.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician supervision of a patient requiring complex and multidisciplinary care modalities The agency covers CPT codes 99339 and 99340 with prior authorization. For supervision services that are less than 30 minutes, use code 99339; and for services exceeding 30 minutes, use code 99340. There is a unit limit of one unit of CPT 99339 or one unit of CPT 99340 per calendar month. Claims are subject to post-payment review. Clear documentation of care plan oversight is required by the agency, including:     

Time allocation. Care plans. Review of diagnostic reports and laboratory studies. Treatment-related communications with other health care professionals and caregivers. Adjustment of medical therapy.

CPT Code 99339

99340

Short Description Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes Within a calendar month; 30 minutes or more

Preventative medicine services HIV/AIDS counseling/testing (CPT code 99401) (WAC 182-531-0600) The agency covers two sessions of risk factor reduction counseling (CPT code 99401) counseling per client, each time tested (i.e., one pre- and one post-HIV/AIDS counseling/testing session). Use ICD diagnosis code Z71.7 when billing CPT code 99401 for HIV/AIDS counseling.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services The agency does not pay for HIV/AIDS counseling when billed with an E/M service unless the client is being seen on the same day for a medical problem and the E/M service is billed with a separately identifiable diagnosis code and with modifier 25. See the agency’s HIV/AIDS Case Management Provider Guide for additional information on HIV/AIDS case management billing.

Prolonged services (CPT codes 99354-99357) (WAC 182-531-1350)

Prolonged services with direct patient contact The agency covers prolonged services: 

Up to three hours per client, per diagnosis, per day. Note: The time counted toward payment for prolonged E/M services includes only direct face-to-face contact between the provider and the client, whether or not the services were continuous.



Only when the provider performs one of the services listed below for the client on the same day: Prolonged CPT Code Outpatient 99354 99355 Prolonged CPT Code Inpatient

Other CPT Code(s) 99201-99215, 99241-99245, 99324-99337, 9934199350, 90815 99354 and one of the E/M codes required for 99354 Other CPT Code(s)

99218-99220, 99221-99233, 99251-99255, 9930499310 99357 99356 and one of the E/M codes required for 99356 Note: Both the prolonged services CPT code and any of the “Other CPT Code(s)” listed above must be billed on the same claim. 99356

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician standby services (CPT code 99360) (WAC 182-531-1250) The agency covers physician standby services when those services are requested by another physician and involve prolonged physician attendance without direct (face-to-face) client contact. Note: The standby physician cannot provide care or services to other clients during the standby period.

Limitations 

Standby services of less than 30 minutes are not covered.



After the first 30 minutes, subsequent periods of standby services are covered only when a full 30 minutes of standby is provided for each unit billed.

The agency does not cover physician standby services when: 

The provider performs a surgery that is subject to the global surgery policy.



Billed in addition to any other procedure code, with the exception of CPT codes 99460 and 99465.



When the service results in an admission to a neonatal intensive care unit (CPT code 99468) on the same day.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Telemedicine (WAC 182-531-1730)

What is telemedicine? Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located. If the service is provided through store and forward technology, there must be an associated office visit between the client and the referring health care provider. Using telemedicine when it is medically necessary enables the health care practitioner and the client to interact in real-time communication as if they were having a face-to-face session. Telemedicine allows agency clients, particularly those in medically underserved areas of the state, improved access to essential health care services that may not otherwise be available without traveling long distances. The agency does not cover the following services as telemedicine:   

Email, audio only telephone, and facsimile transmissions Installation or maintenance of any telecommunication devices or systems Purchase, rental, or repair of telemedicine equipment

Who is eligible for telemedicine? Fee-for-service clients are eligible for medically necessary covered health care services delivered via telemedicine. The referring provider is responsible for determining and documenting that telemedicine is medically necessary. As a condition of payment, the client must be present and participating in the telemedicine visit. Clients under the Family Planning, TAKE CHARGE, First Steps, and School-Based Health Care Services programs are eligible for telemedicine through feefor-service. The agency will not pay separately for telemedicine for services covered under an agencycontracted managed care plan. Clients enrolled in an agency-contracted managed care organization (MCO) are identified as such in ProviderOne. MCO enrollees must have all services arranged and provided by their primary care providers (PCP). Contact the MCO regarding whether or not the plan will authorize telemedicine coverage for services covered under the plan.

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When does the agency cover telemedicine? The agency covers telemedicine when it is used to substitute for an in-person face-to-face, hands-on encounter for only those services specifically listed in this telemedicine section. Clients enrolled in an agency-contracted MCO must contact the MCO regarding whether or not the plan will authorize telemedicine coverage.

Originating site (location of client) What is an originating site? An originating site is the physical location of the eligible agency client at the time the professional service is provided by a physician or practitioner through telemedicine. Approved originating sites are:           

Clinics Community mental health/chemical dependency settings Dental offices Federally qualified health center (FQHC) Home or any location determined appropriate by the individual receiving service Hospitals (inpatient and outpatient) Neurodevelopmental centers Physician or other health professional’s office Rural health clinics (RHC) Schools Skilled nursing facilities

Is the originating site paid for telemedicine? Yes. The originating site is paid a facility fee per completed transmission. The agency does not pay the facility fee to the client in any setting.

How does the originating site bill the agency for the facility fee? 

Hospital outpatient: When the originating site is a hospital outpatient agency, payment for the originating site facility fee will be paid according to the maximum allowable fee schedule. To receive payment for the facility fee, outpatient hospital providers must bill revenue code 0780 on the same line as HCPCS code Q3014.



Hospital inpatient, skilled nursing facility, home, or location determined appropriate by the individual receiving service: There is no payment to the originating site for the facility fee in these settings.

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Critical access hospitals: When the originating site is a critical access hospital outpatient agency, payment is separate from the cost-based payment methodology. To receive payment for the facility fee, critical access hospitals must bill revenue code 0789 on the same line as HCPCS code Q3014.



FQHCs and RHCs: When the originating site is an FQHC or RHC, bill for the facility fee using HCPCS code Q3014. This is not considered an FQHC or RHC service and is not paid as an encounter.



Physicians’ or other health professional offices: When the originating site is a physician’s office, bill for the facility fee using HCPCS code Q3014.



Other settings: When the originating site is an approved telemedicine site, bill for the facility fee using HCPCS Q3014.

If a provider from the originating site performs a separately identifiable service for the client on the same day as telemedicine, documentation for both services must be clearly and separately identified in the client’s medical record.

Distant site (location of consultant) What is a distant site? A distant site is the physical location of the health care professional providing the health care service to an eligible agency client through telemedicine.

What services are covered using telemedicine? The agency reimburses medically necessary covered services through telemedicine when the service is provided by a Washington Apple Health provider and is within their scope of practice.

How does the distant site bill the agency for the services delivered through telemedicine? The payment amount for the professional service provided through telemedicine by the provider at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT codes with modifier GT (via interactive audio and video telecommunications system) when submitting claims to the agency for payment.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Anesthesia (WAC 182-531-0300)

General anesthesia 

The agency requires providers to use anesthesia CPT® codes 00100-01999 to bill for anesthesia services paid with base and time units. Do not use the surgical procedure code with an anesthesia modifier to bill for the anesthesia procedure.



The agency pays for CPT code 01922 for noninvasive imaging or radiation therapy when either of the following applies:  



The agency pays providers for covered anesthesia services performed by one of the following:   



Anesthesiologist Certified registered nurse anesthetist (CRNA) Other providers who have a contract with the agency to provide anesthesia services

For each client, the anesthesia provider must do all of the following:       



The client is 17 years of age or younger. There are client-specific reasons why the procedure cannot be performed without anesthesia services. Documentation must be kept in the client's medical record.

Perform a pre-anesthetic examination and evaluation Prescribe the anesthesia plan Personally participate in the most demanding aspects of the anesthesia plan, including, induction and emergence Ensure that any procedures in the anesthesia plan that he or she does not perform are done by a qualified individual as defined in program operating instructions Monitor the course of anesthesia administration at frequent intervals Remain physically present and available for immediate diagnosis and treatment of emergencies Provide indicated postanesthesia care

The anesthesia provider may direct no more than four anesthesia services concurrently. The anesthesia provider may not perform any other services while directing these services, other than attending to medical emergencies and other limited services as allowed by Medicare policy. CPT® codes and descriptions only are copyright 2015 American Medical Association

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The anesthesia provider must document in the client's medical record that the medical direction requirements were met. Providers do not need to submit documentation with each claim to substantiate these requirements.



Anesthesia time begins when the anesthesia provider starts to physically prepare the client for the induction of anesthesia in the operating room area or its equivalent. When there is a break in continuous anesthesia care, blocks of time may be summed as long as there is continuous monitoring of the client within the blocks of time. An example of this includes, but is not limited to, the time a client spends in an anesthesia induction room or under the care of an operating room nurse during a surgical procedure. Anesthesia time ends when the anesthesia provider or surgeon is no longer in constant attendance (i.e. when the client can be safely placed under postoperative supervision).



Do not bill CPT codes 01953 or 01996 with an anesthesia modifier or with the time in the "units" field. The agency has assigned flat fees for these codes.



The agency does not adopt any ASA RVG codes that are not included in the CPT book. Bill all anesthesia codes according to the descriptions published in the current CPT book. When there are differences in code descriptions between the CPT book and the ASA RVG, the agency follows CPT code descriptions.



The agency does not pay providers for anesthesia services when these services are billed using the CPT surgery, radiology, and/or medicine codes with anesthesia modifiers. Continue to use the appropriate anesthesia modifier with anesthesia CPT codes. Exception: Anesthesia providers may bill CPT pain management/other services procedure codes that are not paid with base and time units. These services are paid as a procedure using RBRVS methodology. Do not bill time in the unit field or use anesthesia modifiers.



When billing for sterilization, details regarding anesthesia are located in the Sterilization Supplemental Provider Guide.



When multiple surgical procedures are performed during the same period of anesthesia, bill the surgical procedure with the greatest base value, along with the total time in whole minutes.



When more than one anesthesia provider is present, the agency pays each provider 50% of the allowed amount. The agency limits payment in this circumstance to 100% of the total allowed payment for the service.



Providers must report the number of actual anesthesia minutes (calculated to the next whole minute) in the appropriate field of the claim form. The agency calculates the base units. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Note: When billing for Medicare crossovers, remember that Medicare pays per the base units and the agency pays per minute of anesthesia. When billing a Medicare crossover on a paper claim or via the Direct Data Entry (DDE) portal, bill the agency using minutes in the unit field. When billing a Medicare crossover on a HIPAA 837P transaction, bill units the same as if billing Medicare.

Regional anesthesia 

Bill the agency the appropriate procedure code (e.g. epidural CPT code 62319) with no time units and no anesthesia modifier. The agency determines payment by using the procedure’s maximum allowable fee, not anesthesia base and time units.



Local nerve block CPT code 64450 (other than digital and metacarpal) for subregional anatomic areas (such as the hand, wrist, ankle, foot and vagina) is included in the global surgical package and is not paid separately.

Other 

The agency does not pay separately for moderate sedation. The agency considers moderate sedation as bundled with the procedure code.



Patient acuity does not affect payment levels. Qualifying circumstances (CPT codes 99100, 99116, 99135, and 99140) are considered bundled and are not paid separately.



The agency follows Medicare’s policy of not paying surgeons for anesthesia services. Claims for anesthesia services with modifier 47 will be denied. Under Medicare's payment policy, separate payment for local, regional, or digital block or general anesthesia administered by the surgeon is not allowed. These services are considered included in the RBRVS payments for the procedure.



When billing for anesthesia services using CPT unlisted anesthesia code 01999, providers must attach documentation (operative report) to their claim indicating what surgical procedure was performed that required the anesthesia, in order to receive payment. The agency will determine payment amount after review of the documentation.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Teaching anesthesiologists The agency pays teaching anesthesiologists for supervision of anesthesiology residents as follows:



When supervising one resident only, the teaching anesthesiologist must bill the agency the appropriate anesthesia procedure code with modifier AA. Payment to the teaching anesthesiologist will be 100% of the allowed amount.



When supervising two or more residents concurrently, the teaching anesthesiologist must bill the agency the appropriate anesthesia procedure codes with modifier QK. Payment to the teaching anesthesiologist will be 50% of the allowed amount for each case supervised.

Physician fee schedule payment for services of teaching physicians General rule: If a resident physician participates in providing a service in a teaching setting, physician fee schedule payment is made only if a teaching physician is present during the key portion of any service or procedure for which payment is sought. 



Surgical, high-risk, or other complex procedures: The teaching physician must be present during all critical portions of the procedure and immediately available to furnish services during the entire service or procedure. 

Surgery: The teaching physician's presence is not required during opening and closing of the surgical field.



Procedures performed through an endoscope: The teaching physician must be present during the entire viewing.

Evaluation and management services: The teaching physician must be present during the portion of the service that determines the level of service billed. (However, in the case of evaluation and management services furnished in hospital outpatient departments and certain other ambulatory settings, the requirements of 42 C.F.R. §415.174 apply.)

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Anesthesia for dental General anesthesia is allowed when provided by an anesthesiology provider in a hospital for dental admissions. To bill for dental anesthesia provided in a hospital, providers must use CPT anesthesia code 00170 with the appropriate anesthesia modifier. See the agency’s Dental-Related Services Provider Guide for information on billing for officebased anesthesia for dental procedures. Note: Bill the agency directly for dental anesthesia for all clients, including those enrolled in an agency-contracted managed care organization.

Anesthesia for maternity (WAC 182-531-0300(9)) 

The agency pays a maximum of 6 hours (360 minutes) of anesthesia for labor and delivery time (CPT codes 01960, 01961, 01967 and 01968) per delivery, including multiple births and/or cesarean section delivery. Exception: The following obstetrical anesthesia codes are not subject to the 6hour (360 minute) limitation: CPT codes 01962-01966 or 01969.



When billing more than one time-limited anesthesia code, the total time may not exceed 6 hours (360 minutes).



Bill the applicable CPT anesthesia code with applicable modifier and time. To determine time for obstetric epidural anesthesia during normal labor and delivery and C-sections, time begins with insertion and ends with removal for a maximum of 6 hours per delivery.



CPT codes 01968 and 01969 are anesthesia add-on codes to be used for cesarean delivery and cesarean hysterectomy following anesthesia given for a planned vaginal delivery. An additional base of 3 is allowed for 01968 and an additional base of 5 is allowed for 01969, in conjunction with the base of 5 for 01967. The time involved with each portion of the procedure should be reported with the appropriate CPT code. For example: When a physician starts a planned vaginal delivery (CPT code 01967) and it results in a cesarean delivery (CPT code 01968), both of these procedures may be billed. However, if both an anesthesiologist and a certified registered nurse assistant (CRNA) are involved, each provider bills only for those services he/she performed. The sum of the payments for each procedure will not exceed the agency’s maximum allowable fee.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Anesthesia time for sterilization is added to the time for the delivery when the two procedures are performed during the same operative session. If the sterilization and delivery are performed during different operative sessions, the time is calculated separately.

Anesthesia for radiological procedures (WAC 182-531-0300 (2) and (7)) General anesthesia is allowed for radiological procedures for children and/or noncooperative clients when the medically necessary procedure cannot be performed unless the client is anesthetized. Providers must use the anesthesia CPT code 01922 when providing general anesthesia for noninvasive imaging or radiation therapy. Do not bill the radiological procedure code (e.g., CPT code 71010) with an anesthesia modifier to bill for the anesthesia procedure. When using CPT code 01922 for noninvasive imaging or radiation therapy, one of the following must be met: 

The client must be 17 years of age or younger.



A statement of the client-specific reasons why the procedure cannot be performed without anesthesia services must be kept in the client's medical record and made available to the agency on request.

Anesthesia payment calculation for services paid with base and time units   

The agency’s current anesthesia conversion factor is $21.20. Anesthesia time is paid using one minute per unit. Total anesthesia payment is calculated by adding the base value for the anesthesia procedure with the actual time. Bill time in total minutes only, rounded to the next whole minute. Do not bill the procedure’s base units.

The following table illustrates how to calculate the anesthesia payment:

A. B. C. D.

Payment Calculation Multiply base units by 15. Add total minutes to value from step A. Divide anesthesia conversion factor by 15, to obtain the rate per minute. Multiply total from Step B by the rate per minute in Step C.

Anesthesia conversion factor is based on 15-minute time units. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Surgery (WAC 182-531-1700) The agency requires prior authorization for selected surgical procedures. Providers must check the Physician-Related Services Fee Schedule for those surgical services that require either prior authorization (PA) or expedited prior authorization (EPA).

Smoking cessation Nicotine use is a strong contraindication to spine surgeries. Patients undergoing cervical fusions and repeat fusions for radiculopathy are required to abstain from nicotine for four weeks before surgery. The agency covers smoking cessation which can include free counseling and prescription drugs. See Behavior Change Intervention - Smoking Cessation.

Pain management services 

Pain management services and selected surgical services that are commonly performed by anesthesiologists and CRNAs are not paid with anesthesia base and time units. These services are paid using the agency’s assigned maximum allowable fee for the procedure code.



When billing for pain management and other services that are payable using the agency’s assigned maximum allowable fee, do not use anesthesia modifiers. The agency denies claims for these services billed with an anesthesia modifier.



Two postoperative procedures for pain management are allowed during the same inpatient stay. Only one (1) unit may be billed per procedure. Do NOT bill time.

Pain management procedure codes The listings shown below are not guaranteed to be all-inclusive and are provided for convenience purposes only. The procedure codes listed in the following table with an asterisk (*) are limited to two (2) during the postoperative period while the client is admitted to the hospital. Do not bill modifier 59, XE, XS, XP, or XU with any of these procedure codes.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Procedure Code 11981* 11982* 11983* 20526* 20550 20551 20552 20553 20600 20605 20610 20612 27096 61790* 62264* 62270 62272 62273* 62280* 62281* 62282* 62284 62290 62291 62310* 62311* 62318* 62319* 62350* 62351* 62355* 62360* 62361* 62362* 62365* 63650* 63655* 63685* 63688* 64400* 64402* 64405*

Short Description Insert drug implant device Remove drug implant device Remove/insert drug implant Ther injection carp tunnel Inj tendon/ligament Inj tendon origin/insertion Inj trigger point 1/2 muscl Inject trigger points 3/> Drain/inject joint/bursa Drain/inject joint/bursa Drain/inject joint/bursa Aspirate/inj ganglion cyst Inject sacroiliac joint Treat trigeminal nerve Epidural lysis on single day Spinal fluid tap diagnostic Drain cerebro spinal fluid Inject epidural patch Treat spinal cord lesion Treat spinal cord lesion Treat spinal canal lesion Injection for myelogram Inject for spine disk x-ray Inject for spine disk x-ray Inject spine cerv/thoracic Inject spine lumbar/sacral Inject spine w/cath, c/t Inject spine w/cath lmb/scrl Implant spinal canal cath Implant spinal canal cath Remove spinal canal catheter Insert spine infusion device Implant spine infusion pump Implant spine infusion pump Remove spine infusion device Implant neuroelectrodes Implant neuroelectrodes Insrt/redo spine n generator Revise/remove neuroreceiver N block inj trigeminal N block inj facial N block inj occipital CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Procedure Code 64408* 64410* 64412* 64413* 64415* 64416* 64417* 64418* 64420* 64421* 64425* 64430* 64435* 64445* 64446* 64447* 64448* 64449* 64450* 64479* 64480* 64483* 64484* 64505* 64508* 64510* 64517* 64520* 64530* 64553* 64555* 64561* 64565* 64575* 64580* 64581* 64585* 64590* 64595* 64600* 64605* 64610*

Short Description N block inj vagus N block inj phrenic N block inj spinal accessor N block inj cervical plexus N block inj brachial plexus N block cont infuse b plex N block inj axillary N block inj suprascapular N block inj intercost sng N block inj intercost mlt N block inj ilio-ing/hypogi N block inj pudendal N block inj paracervical N block inj sciatic sng N blk inj sciatic cont inf N block inj fem single N block inj fem cont inf N block inj lumbar plexus N block other peripheral Inj foramen epidural c/t Inj foramen epidural add-on Inj foramen epidural l/s Inj forament epidural add-on N block spenopalatine gangl N block carotid sinus s/p N block stellate ganglion N block stellage ganglion N block lumbar/thoracic N block inj celiac pelus Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes (PA) Implant neuroelectrodes (PA) Implant neuroelectrodes (PA) Revised/remove neuroelectrode (PA) Insrt/redo pn/gastr stimul (PA) Revise/rmv pn/gastr stimul (PA) Injection treatment of nerve Injection treatment of nerve Injection treatment of nerve CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Procedure Code 64612* 64616* 64617* 64620* 64630* 64640* 64680* 64681* 64802* 64804* 64809* 64818*

Short Description Destroy nerve face muscle Chemodenerv musc neck dyston Chemodener muscle larynx emg Injection treatment of nerve Injection treatment of nerve Injection treatment of nerve Injection treatment of nerve Injection treatment of nerve Remove sympathetic nerves Remove sympathetic nerves Remove sympathetic nerves Remove sympathetic nerves

Other Services

Procedure Code 36400 36420 36425 36555 36566 36568 36580 36584 36589 36600 36620 36625 36660 62263 62287 63600 76000 76496 77001 77002 77003 93503 95970 95990

Short Description Bl draw < 3 yrs fem/jugular Vein access cutdown < 1 yr Vein access cutdown > 1 yr Bl exchange/transfuse non-nb Insert tunneled cv cath Insert picc cath Replace cvad cath Replace picc cath Removal tunneled cv cath Withdrawal of arterial blood Insertion catheter artery Insertion catheter artery Insertion catheter artery Epidural lysis mult sessions Percutaneous discectomy Remove spinal cord lesion Fluoroscope examination Fluoroscopic procedure Fluoroguide for vein device Needle localization by xray Fluoroguide for spine inject Insert/place heart catheter Analyze neurostim no prog Spin/brain pump refil & main

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services These codes are paid as a procedure using the agency’s maximum allowable fee, not with base units and time.

Interoperative or postoperative pain management The agency covers interoperative and postoperative pain control using a spinal injection or infusion (CPT® 62310, 62311, 62318, 62319). Expedited prior authorization (EPA) is required. See EPA #870001351. If the client does not meet the EPA criteria, prior authorization (PA) is required (see Prior Authorization).

Registered Nurse First Assistants Registered Nurse First Assistants (RNFAs) are allowed to assistant at surgeries within their scope of practice. Use modifier AS to bill the agency for these services. New RNFA providers must meet all of the following criteria:   

Licensed in Washington State as a Registered Nurse in good standing Work under the direct supervision of the performing surgeon Hold current certification as a certified nurse operating room (CNOR)

Submit all of the following documentation to the agency along with the Core Provider Agreement: 

Proof of current certification as a CNOR from the Certification Board Perioperative Nursing



Proof of successful completion of an RNFA program that meets the Association of Perioperative Registered Nurses (AORN) standards for RN first assistant education programs. (See Perioperative Standards and Recommended Practices, Denver, CO: AORN)



Proof of allied health personnel privileges in the hospital where the surgeries are performed



Proof of liability insurance

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Billing/Payment Bilateral procedures 

If a procedure is done bilaterally and is identified by its terminology as bilateral (e.g. CPT codes 27395 or 52290), do not bill the procedure with modifier 50.



If a procedure is done bilaterally and is not identified by its terminology as a bilateral procedure, bill the procedure using modifier 50 on one line only or include modifier LT or RT on the separate lines when the surgical procedure is performed on both sides.



Use modifiers LT and RT to indicate left and right for unilateral procedures.

Bundled services The following procedure codes are bundled within the payment for the surgical procedure during the global period. Do not bill these codes separately unless one of the conditions on the following page exists: Procedure Code E/M Services

Short Description

Office visits, initial hospital observation care, and initial hospital inpatient care Subsequent hospital care, observation or inpatient care 99231-99239 services, and hospital discharge services 99241-99245 Office consultations 99291-99292 Critical care services. 99307-99310 Subsequent nursing facility care 99324-99337 Domiciliary, rest home, or custodial care services 99347-99350 Home services Ophthalmological Services 92012-92014 General ophthalmological services 99211-99223

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services The E/M codes listed above may be allowed if there is a separately identifiable reason for the additional E/M service unrelated to the surgery. In these cases, the E/M code must be billed with one of the following modifiers: Modifier Description 

24

Unrelated E/M service by the same physician during a postoperative period (reason for the E/M service must be unrelated to the procedure)



25

Significant, separately identifiable E/M service by the same physician on the same day of a procedure (reason for the E/M service must be unrelated to the procedure)



57

Decision for surgery (only applies to surgeries with a 90-day global period)



79

Unrelated procedure or service by the same physician during the postoperative period



Professional inpatient services (CPT codes 99221-99223) are payable only during the global follow-up period if they are performed on an emergency basis (i.e. they are not payable for scheduled hospital admissions).



Bundled procedure codes are not payable during the global surgery payment period.

A provider (other than the surgeon) who provides all postoperative care (including all inpatient postoperative care) before discharge, must bill subsequent hospital care codes (CPT codes 99231-99233) for the inpatient hospital care, and the surgical code with modifier 55 for the postdischarge care. The surgeon must bill the surgery code with modifier 54. 

Providers who perform only the follow-up services for minor procedures performed in emergency agencies must bill the appropriate level E/M code. These services are not included in the global surgical payment.



The provider who performs the emergency room service must bill for the surgical procedure without using modifier 54.



Preoperative and postoperative critical care services provided during a global period for a seriously ill or injured client are not considered related to a surgical procedure and are paid separately when all of the following apply:



The client is critically ill or injured and requires the constant attendance of the provider.



The critical care is unrelated to the specific anatomic injury or general surgical procedure performed. CPT® codes and descriptions only are copyright 2015 American Medical Association

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The client is potentially unstable or has conditions that could pose a significant threat to life or risk of prolonged impairment.

Bill the appropriate critical care codes with either modifier 24 or 25. 

The agency allows separate payment for:



The initial evaluation to determine need for surgery.



Preoperative visits that occur two or more days before the surgery. Use the specific medical diagnosis for the client. Do not use Z01.812 or Z01.818 or Z01.89.



Postoperative visits for problems unrelated to the surgery.



Postoperative visits for services that are not included in the normal course of treatment for the surgery.



Services of other providers, except when more than one provider furnishes services that are included in a global package (see modifiers 54 and 55).

Global surgery payment Global surgery payment includes all the following services: 

The surgical procedure



For major surgeries (90-day global period), preoperative visits (all sites of service) that occur the day before or the day of the surgery



For minor surgeries (less than 90-day global period), preoperative visits (all sites of service) that occur on the day of surgery



Services by the primary surgeon (all sites of service) during the postoperative period



Postoperative dressing changes, including all of the following:

  

Local incision care and removal of operative packs Removal of cutaneous sutures, staples, lines, wires, tubes, drains and splints; Insertion, irrigation and removal of urinary catheters, routine peripheral IV lines, nasogastric and rectal tubes CPT® codes and descriptions only are copyright 2015 American Medical Association

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 

Change and removal of tracheostomy tubes

Additional medical or surgical services required because of complications that do not require additional operating room procedures Note: Casting materials are not part of the global surgery policy and are paid separately.

Global surgery payment period 

The global surgery payment period applies to any provider who participates in the surgical procedure. These providers include:

     

The surgeon. The assistant surgeon (modifiers 80, 81, or 82). Two surgeons (modifier 62). Team surgeons (modifier 66). Anesthesiologists and CRNAs. Physician assistant, nurse practitioner, or clinical nurse specialist for assistant at surgery (modifier AS).

Multiple surgeries When multiple surgeries are performed on the same client, during the same operative session, the agency pays providers:  

100% of the agency’s maximum allowable fee for the most expensive procedure; plus, 50% of the agency’s maximum allowable fee for each additional procedure.

To expedite payment of claims, bill all surgeries performed during the same operative session on the same claim. This includes secondary claims with payment by a primary commercial insurance and Medicare crossover claims. If a partial payment is made on a claim with multiple surgeries, providers must adjust the paid claim. Refer to the ProviderOne Billing and Resource Guide, Key Step 6 under “Submit Fee for Service Claims to Medical Assistance” which addresses adjusting paid claims. Providers may adjust claims electronically in ProviderOne (preferred) or send in a paper claim adjustment. Note: For second operative session performed on the same date of service (e.g., return to the operating room for a staged procedure), bill the second operative session on a separate claim. Add in the claim comments, “Operative reports attached” and submit claim to the agency with operative reports. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Other surgical policies 

Use modifiers 80, 81, and 82 to bill for an assistant surgeon. An assistant at major surgery is paid at 20% of the surgical procedure’s maximum allowable fee. The multiple surgery rules apply for surgery assistants.



Use modifier AS for an assistant at surgery for PA-Cs, ARNPs, or Clinical Nurse Specialists – do not use modifier 80. An assistant at major surgery is paid at 20% of the surgical procedure’s maximum allowable fee.



To expedite payment of claims, bill for the assistant surgeon on a different claim.



A properly completed consent form must be attached to all claims for sterilization and hysterectomy procedures. For sterilizations, see the Sterilization Supplemental Provider Guide. For hysterectomies, see the hysterectomy section of this guide.)



Microsurgery Add On CPT Code 69990 CPT indicates that CPT code 69990 is not appropriate when using magnifying loupes or other corrected vision devices. Also, CPT code 69990 is not payable with procedures where use of the operative microscope is an inclusive component of the procedure (i.e. the procedure description specifies that microsurgical techniques are used). The agency follows CCI guidelines regarding the use of the operating microscope. Do not bill CPT code 69990 in addition to procedures where the use of the operating microscope is an inclusive component.



The agency pays for the following procedure codes which include breast removal and breast reconstruction for clients who have breast cancer or history of breast cancer, burns, open wound injuries, or congenital anomalies of the breast. If a client does not have one of these conditions, the service requires prior authorization (PA).



Removal of failed breast implants with the appropriate ICD diagnosis code T85.41XA or T85.42XA requires PA. The agency will pay to remove implants (CPT codes 19328 and 19330) but will not replace them if they were placed for cosmetic reasons.



The agency requires EPA for reduction mammoplasties (CPT code 19318) and for mastectomy for gynecomastia for men (CPT code 19300). See Expedited Prior Authorization for more information.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services CPT Code(s) 11920 11921 11960 11970 11971 19301 19302 19303 19304 19316 19340 19342 19350 19357 19361 19364 19366 19367 19368 19369 19370 19371 19380 S2066 S2067

Short Description Correct skin color defects 6.0 cm (use V10.3) (Tattoo) Correct skin color 6.1-20.0 cm Insertion tissue expander(s) Replace tissue expander Remove tissue expander(s) Partial mastectomy P-mastectomy w/ln removal Mast simple complete Mast subq Suspension of breast Immediate breast prosthesis Delayed breast prosthesis Breast reconstruction Breast reconstruction Breast reconstr w/lat flap Breast reconstruction Breast reconstruction Breast reconstruction Breast reconstruction Breast reconstruction Surgery of breast capsule Removal of breast capsule Revise breast reconstruction Breast GAP flap reconst Breast "stacked" DIEP/GAP

Limitations

Limited to the appropriate ICD diagnosis codes. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.



Salpingostomies (CPT codes 58673 and 58770) are payable only for a tubal pregnancy (ICD diagnosis code O00.1).



Modifier 53 must be used when billing for incomplete colonoscopies (CPT code 45378, or HCPCS codes G0105 or G0121). Do not bill incomplete colonoscopies as sigmoidoscopies. Modifier 53 indicates that the physician elected to terminate a surgical procedure. Use of modifier 53 is allowed for all surgical procedures. Modifier 53 is a payment modifier when used with CPT code 45378 or HCPCS codes G0105 or G0121. It is informational only for all other surgical procedures.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Panniculectomy Panniculectomy requires prior authorization (PA). Photographs and supporting clinical documentation must be submitted with PA requests. All of the following must be present for panniculectomy:  

The pannus hangs at or below the level of the symphysis pubis The pannus causes a chronic and persistent skin condition (e.g., intertriginous dermatitis, panniculitis, cellulitis, or skin ulcerations) that is refractory to at least three months of medical treatment and associated with at least one episode of cellulitis requiring systemic antibiotics. In addition to good hygiene practices, all of the following treatments (unless contraindicated) have been tried and failed: topical antifungals, topical or systemic corticosteroids, and local or systemic antibiotics The pannus causes a functional deficit because of a severe physical deformity or disfigurement The surgery is expected to restore or improve the functional deficit The pannus is interfering with daily living

  

How do providers get paid for implantable devices? To receive payment for implantable devices, providers must: 

Use HCPCS procedure codes C1713 or L8699.



Bill for implantable devices on the same claim as the primary procedure code associated with the device. The primary procedure code must be covered on the agency’s Physician-Related Services/Professional Health Care Services fee schedule. Claims without a primary procedure code on the claim will be denied.



Use HCPCS procedure codes C1713 or L8699 only once per claim. Bill multiple units if appropriate.



Bill the agency the acquisition cost (AC). AC is the item’s cost minus shipping, handling, and taxes listed in a manufacturer’s invoice. Submit both the manufacturer’s invoice and the claim to the agency for procedures listed as AC.

If the implantable device is a necessary supply, not an “over and above” supply, CPT considers it inclusive to the procedure code billed, and the agency will not reimburse separately. For CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services example, in order to place the tympanostomy tube, the tube is a necessary supply, not an “over and above” supply. Under CPT, this supply is included in the procedure code billed.

Pre-/intra-/postoperative payment splits Pre-, intra-, and postoperative payment splits are made when modifiers 54, 55, 56, and 78 are used. The agency has adopted Medicare's payment splits. If Medicare has not assigned a payment split to a procedure, the agency uses a payment split of 10%/80%/10% if modifiers 54, 55, 56, and 78 are used. For current information and updates on Medicare payment splits, see the Medicare Physician Fee Schedule (MPFS).

Auditory system Tympanostomies The agency covers tympanostomies for clients diagnosed with acute otitis media or otitis media with effusion. Expedited prior authorization (EPA) is required. See EPA #870001382. If the client does not meet the EPA criteria, prior authorization (PA) is required (see Prior Authorization).

Cochlear implant services (clients age 20 and younger) (WAC 182-531-0200(4) (c)) Unilateral (CPT code 69930) and bilateral (CPT code 69930 with modifier 50) cochlear implantation require EPA (see EPA#870000423 for unilateral and EPA#870001365 for bilateral). If a client does not meet the EPA criteria, PA is required. The agency covers replacement parts for cochlear devices through the agency’s Hearing Aids and Services Program only. The agency pays only those vendors with a current core provider agreement that supply replacement parts for cochlear implants and bone-anchored hearing aids (BAHA). Note: The agency does not pay for new cochlear implantation for clients age 21 and older. The agency considers requests for removal or repair of previously implanted cochlear implants for clients age 21 and older when medically necessary. Prior authorization is required.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services CPT Codes 69930 69715

Short Description

Comments No corresponding removal codes specific to cochlear devices.

Implant cochlear device

Temple bne implnt w/stimulat

BAHA for clients age 20 and younger Insertion or initial placement of BAHAs (CPT codes 69714-69718; HCPCS L8693) requires prior authorization (PA) (refer to Prior Authorization). For billing the initial placement of soft headband BAHA, use the appropriate E/M procedure code and the appropriate hardware HCPCS code. See the agency’s Hearing Hardware for Clients 20 Years of Age and Younger Fee Schedule. Note: This information relates only to those clients NOT enrolled in an agencycontracted managed care organization (MCO). For clients enrolled in an agencycontracted MCO, refer to the coverage guidelines in the enrollee’s plan. The procedure can be performed in an inpatient hospital setting or outpatient hospital setting. The agency covers replacement parts or repair for BAHA through the agency’s Hearing Hardware for Clients 20 Years of Age and Younger Program only. The agency pays only those vendors that supply replacement parts for cochlear implants and BAHA who have a current Core Provider Agreement. Note: The agency does not pay for a new BAHA for clients age 21 and older. The agency considers requests for removal or repair of previously implanted BAHA for clients age 21 and older when medically necessary. PA is required.

CPT Code

Notes

Short Description

69710

Implant/replace hearing aid

69711 69714 69715 69717 69718

Remove/repair hearing aid Implant temple bone w/stimul Temple bne implnt w/stimulat Temple bone implant revision Revise temple bone implant

Replacement procedure includes removal of the old device

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Cardiovascular system Carotid Artery Stenting The agency pays for extracranial carotid artery stenting: 

When performed in an agency-accredited facility as determined by CMS. For a list of accredited facilities, see CMS’s web page for Carotid Artery Stenting Facilities.



For patients who are at high surgical risk for carotid endarterectomy (CEA) and who also have one of the following:  Symptomatic carotid artery stenosis >50%  Asymptomatic carotid artery stenosis ≥80%

Patients at high surgical risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., recurrent stenosis and/or previous radical neck dissection), and would be poor candidates for CEA. Significant comorbid conditions include, but are not limited to the following:        

Congestive heart failure (CHF) class III/IV Left ventricular ejection fraction (LVEF) < 30 % Unstable angina Contralateral carotid occlusion Recent myocardial infarction (MI) Previous CEA with recurrent stenosis Prior radiation treatment to the neck and Other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC II

The agency does not pay for carotid artery stenting of intracranial arteries.

Vericose vein treatment The agency pays for the following varicose vein treatment when prior authorized: Sclerosing solution injection: CPT codes 36468, 36469, 36470, 36471 Endovascular Ablation: CPT codes 36475, 36476, 36478, 36479 Stab Phlebectomy: CPT codes 37765 and 37766 Ligation, division and stripping: CPT codes 37718, 37722, 37735, 37760, 37761 CPT® codes and descriptions only are copyright 2015 American Medical Association

98

Physician-Related Services/Health Care Professional Services

Digestive system Diagnostic upper endoscopy for GERD Diagnostic upper endoscopy for adults with gastroesophageal reflux disease (GERD) may be considered medically necessary with one of the following conditions: 

Failure of an adequate trial of medical treatment to improve or resolve symptoms



Presence of the following alarm symptoms:    

Persistent dysphagia or odynophagia Persistent vomiting of unknown etiology Evaluation of epigastric mass Confirmation and specific histological diagnosis of radiologically demonstrated lesions  Evaluation for chronic blood loss and iron deficiency anemia when an upper gastrointestinal source is suspected or when colonoscopy results are negative  Progressive unintentional weight loss

This policy does not apply to therapeutic endoscopy (e.g., removal of foreign body) or for clients with known esophageal or gastric varices or neoplasms, inflammatory bowel disease, familial adenomatous polyposis syndrome, biopsy confirmed Barrett’s esophagus, biopsy confirmed esophageal or gastric ulcers, history of upper gastrointestinal stricture. CPT Code 43200 43202 43234 43235 43239

Short Description Esophagus endoscopy Esophagus endoscopy biopsy Upper gi endoscopy exam Uppr gi endoscopy diagnosis Upper gi endoscopy biopsy

Closure of enterostomy Mobilization of splenic flexure (CPT code 44139) is not paid when billed with enterostomy procedures (CPT codes 44625 and 44626). CPT code 44139 must be used only in conjunction with partial colectomy (CPT codes 44140-44147).

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Fecal microbiota therapy Fecal microbiota therapy (FMT) requires prior authorization. FDA position update: The FDA announced that it would exercise enforcement discretion regarding FMT. As long as the treating physician obtains adequate informed consent from the patient or the patient’s legally authorized representative for the procedure, the FDA will not require submission of an Investigational New Drug Application (IND). Informed consent should include, at a minimum, a statement that the use of FMT products to treat C. difficile is investigational and include a discussion of its potential risks. The FDA will exercise this discretion on an interim basis while the agency develops appropriate policies for the study and use of FMT products under IND.

HCPCS Code G0455

Short Description Fecal microbiota prep instil

Drug eluting stents The agency pays for drug eluting stents when the technology criteria are met. This procedure requires EPA. See expedited prior authorization (EPA) criteria for EPA #870000422.

Cardiovascular Angioscopy The agency pays for one unit of angioscopy (CPT code 35400), per session.

Apheresis Therapeutic apheresis (CPT codes 36511-36516) includes payment for all medical management services provided to the client on the date of service. The agency pays for only one unit of either CPT code per client, per day, per provider. Separate payment is not allowed for the following procedures on the same date that therapeutic apheresis services are provided, unless a significant and separately identifiable condition exists which is reflected by the diagnosis code and billed with modifier 25: CPT® codes and descriptions only are copyright 2015 American Medical Association

100

Physician-Related Services/Health Care Professional Services CPT Code 99211 99212 99213 99214 99215 99231 99232 99233

Short Description Office/outpatient visit est Office/outpatient visit est Office/outpatient visit est Office/outpatient visit est Office/outpatient visit est Subsequent hospital care Subsequent hospital care Subsequent hospital care

Do not bill apheresis management when billing for critical care time (CPT codes 99291-99292).

Transcatheter aortic valve replacement (TAVR) (CPT codes 33361-33365, and HCPCS code 0318T) Transcatheter aortic valve (TAVR) is considered medically necessary only for the treatment of severe symptomatic aortic valve stenosis when all of the following occur: 

Prior authorization (PA) must be obtained for the procedure.



Provide the NPI for each team surgeon for payment.



The heart team and hospital must be participating in a prospective, national, audited registry approved by CMS.



Conditions of the CMS Medicare National Coverage Determination must be met.

Note: The agency does not pay for TAVR for indications not approved by the FDA, unless treatment is being provided in the context of a clinical trial and PA has been obtained.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Percutaneous pulmonary valve implantation (PPVI) The agency will cover PPVI with prior authorization (PA) for adult patients and children. To obtain PA the client: 

Must have right ventricular outflow tract (RVOT) dysfunction following prior RVOT repair;



Must have conduits equal to or larger than 16 millimeters (mm) and equal to or smaller than 22 mm;



Cannot undergo, or would like to delay, pulmonary valve replacement through open heart surgery; and



Must have one of the following dx codes:            

I37.x* – Nonrheumatic pulmonary valve disorders I37.0 – Nonrheumatic pulmonary valve stenosis I37.1 – Nonrheumatic pulmonary valve insufficiency I37.2 – Nonrheumatic pulmonary valve stenosis with insufficiency I37.8 – Other nonrheumatic pulmonary valve disorders I37.9 – Nonrheumatic pulmonary valve disorder, unspecified Q21.3 –Tetralogy of Fallot Q22.x* – Congenital malformations of pulmonary and tricuspid valves Q22.0 – Pulmonary valve atresia Q22.1 – Congenital pulmonary valve stenosis Q22.2 – Congenital pulmonary valve insufficiency Q22.3 – Other congenital malformations of pulmonary valve

*The x represents a range of codes; it is dependent on the specific diagnosis.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Female genital system Hysterectomies (WAC 182-531-1550(10)) Prior authorization for hysterectomies is required regardless of the client’s age. Some hysterectomy procedures will require a medical necessity review by the agency to establish medical necessity. However, the agency will use expedited prior authorization (EPA) criteria, instead of a medical necessity review, for one of the following clinical situations:  

Cancer Trauma

For more information, including the EPA numbers and specific criteria, refer to Expedited Prior Authorization (EPA). 

Hysterectomies are paid only for medical reasons unrelated to sterilization.



Federal regulations prohibit payment for hysterectomy procedures until a properly completed Hysterectomy Consent and Patient Information form, 13-365 is received. To comply with this requirement, surgeons, anesthesiologists, and assistant surgeons must obtain a copy of a completed agency-approved consent form to attach to their claim.



ALL hysterectomy procedures require a properly completed agency-approved Hysterectomy Consent and Patient Information Form, 13-365, regardless of the client's age or the ICD diagnosis.



Submit the claim and completed agency-approved consent form (see Resources Available). Download the Hysterectomy Consent and Patient Information Form, 13-365.

Sterilizations (WAC 182-531-1550)

Information on sterilization, instructions on how to complete the sterilization consent form and how to become an approved hysteroscopic sterilization provider are available in the agency’s Sterilization Supplemental Provider Guide.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Integumentary system Clarification of coverage policy for miscellaneous procedures Limitations on coverage for certain miscellaneous procedures are listed below: Procedure Code

Short Description

Prior Authorization

11980 S0189

Implant hormone pellet(s) Testosterone pellet 75 mg

Y Y

S0139

Minoxidil, 10 mg

N

Limitation Restricted to Approved Diagnosis Code Use the appropriate diagnosis code and only when used with CPT code 11980. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals. I10 (essential hypertension)

Male genital system Circumcisions (CPT codes 54150, 54160, and 54161) Circumcisions are covered when billed with one of the following diagnoses:   

Phimosis (ICD diagnosis code N47.3 - N47.8) Balanoposthitis (ICD diagnosis code N47.0 – N47.8, N48.1) Balanitis Xerotica (ICD diagnosis code N48.0)

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Musculoskeletal system Artificial disc replacement The agency pays for Cervical Disc Replacement (CPT codes 22856 and 22861) when the technology criteria are met. These procedures require a medical necessity review by Qualis Health. The agency pays for Lumbar Disc Replacement (CPT codes 22857, 22862, and 22865) when the technology criteria are met. These procedures require a medical necessity review by Qualis Health.

Bone growth stimulators The agency pays for bone growth stimulators (CPT codes 20974, 20975, and 20979) when the technology criteria are met. These procedures require prior authorization (PA) to establish medical necessity.

Bone morphogenetic protein 2 for lumbar fusion The agency requires that the following criteria be met for the use of bone morphogenetic protein -2 (rhBMP-2): 

Clients are age 18 and older.



It is used only in the lumbar spine. And



It is used in primary anterior open or minimally invasive fusion at one level between L4 and S1. Or



Revision of lumbar fusion when autologous bone or bone marrow harvest is not technically feasible, or is not expected to result in fusion for clients who are diabetic, smokers or have osteoporosis.



Lumbar fusion is not covered for clients with a diagnosis of degenerative disc disease. Note: The agency requires a medical necessity review by Qualis Health for associated spinal fusion procedures. Include in the request for authorization:   OR 

The anticipated use of BMP -2 and The miscellaneous CPT code 22899. Diagnosis code 3E0U0GB, insertion of recombinant bone morphogenetic protein. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Bone morphogenetic protein 7 for lumbar fusion The agency will not pay for bone morphogenetic protein – 7 (rhBMP-7) as supporting clinical evidence has not been established.

Cervical spinal fusion arthrodesis The agency pays for cervical spinal fusion for degenerative disc disease with limitations. For clients 20 age and younger, the agency does not require prior authorization for these services. For clients age 21 and older, the agency requires a medical necessity review by Qualis Health.

Limitations of Coverage Cervical spinal fusion is covered when all of the following conditions are met:  Patients have signs and symptoms of radiculopathy  There is advanced imaging evidence of corresponding nerve root compression  Conservative (non-operative) care has failed

Cervical surgery for radiculopathy and myelopathy The agency may cover cervical surgery for neck pain when there is subjective, objective and imaging evidence of radiculopathy or myelopathy. For clients age 20 and younger, the agency does not require prior authorization for the surgeries listed below. For clients age 21 and older the surgeries listed below require a medical necessity review by Qualis Health.        

ACDF anterior cervical discectomy with fusion TDA total disc arthroplasty Laminotomy Laminectomy with or without a fusion Laminoplasty Foraminotomy Corpectomy Repeat surgeries

*For nicotine users: Abstinence from nicotine for at least four weeks before surgery as shown by two negative urine cotinine tests is highly recommended for all fusions and repeat fusions done for radiculopathy. This does not apply to progressive myelopathy or motor radiculopathy. Smoking cessation services are a covered benefit. See Smoking Cessation. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Endoscopy procedures Endoscopy procedures are paid as follows: 

When multiple endoscopies from the same endoscopy group are performed on the same day, the procedure with the highest maximum allowable fee is paid the full amount. The second, third, etc., are paid at the maximum allowable amount minus the base endoscopy procedure's allowed amount.



When multiple endoscopies from different endoscopy groups are billed, the multiple surgery rules detailed above apply.



When payment for other procedures within an endoscopy group is less than the endoscopy base code, no payment is made.



The agency does not pay for an E/M visit on the same day as the diagnostic or surgical endoscopy procedure unless there is a separately identifiable service unrelated to the endoscopy procedure. If it is appropriate to bill the E/M code, use modifier 25.

Epiphyseal Epiphyseal surgical procedures (CPT codes 25450, 25455, 27185, 27475, 27477-27485, 27742, and 27730-27740) are allowed only for clients age 17 and younger.

Hip resurfacing The agency pays for total hip resurfacing arthroplasty as an alternative to total hip arthroplasty when all of the following conditions are met: 

There is a diagnosis of osteoarthritis or inflammatory arthritis.



The individual has failed nonsurgical management and is a candidate for total hip arthroplasty.



The device is FDA-approved.

Hip surgery for femoroacetabular impingement syndrome Medical necessity has not been established for hip surgery to treat Femoroacetabular Impingement Syndrome (FAI). CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Knee arthroscopy for osteoarthritis The agency does not recognize lavage, debridement and/or shaving of the knee (CPT code 29877) as medically necessary when these are the only procedure(s) performed during the arthroscopy. The agency does not reimburse for CPT code 29877 under these circumstances. The agency will pay for arthroscopies done for other diagnostic and therapeutic purposes. This requires a medical necessity review by Qualis Health.

Microprocessor-controlled lower limb prostheses Microprocessor-controlled lower limb prostheses (MCP) for the knee is considered medically necessary for both of the following conditions:  

Functional levels 3 or 4, (level 2 is under agency review) Experienced user, (exceptions are under agency review)

MCP must be used with manufacturers’ specifications. Prior authorization is required. For additional information and authorization requirements, see the agency’s Prosthetic & Orthotic Devices Provider Guide. Note: Microprocessor-controlled lower limb prostheses (MCP) for the feet and ankle are not considered medically necessary.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Osteochondral allograft and autograft transplantation The agency does not recognize osteochondral allograft or autograft transplantation for joints other than the knee as medically necessary. Osteochondral allograft or autograft transplantation in the knee joint may be considered medically necessary. Osteochondral allograft or autograft transplantation is considered medically necessary under all of the following conditions: 

The client is younger than 50 years of age.



There is no presence of malignancy, degenerative arthritis or inflammatory arthritis in the joint.



There is a single focal full-thickness articular cartilage defect that measures less than 3 cm in diameter and 1 cm in bone depth on the weight bearing portion of the medial or lateral femoral condyle.

The following codes are covered and require a medical necessity review by Qualis Health for clients age 21 and older: CPT Code 29866 29867 29868

Short Description Autgrft implnt knee w/scope Allgrft implnt knee w/scope Meniscal trnspl knee w/scpe

Osteotomy reconstruction Procedure Code 21198

Short Description Reconstr lwr jaw segment

Does not require PA when billed with the appropriate ICD diagnoses See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Percutaneous kyphoplasty, vertebroplasty and sacroplasty The agency does not recognize percutaneous kyphoplasty, vertebroplasty and sacroplasty as medically necessary for relief of pain and improvement of function for spinal fractures. CPT Code 22520 22521 22522 22523 22524 22525 72291 72292 0200T 0201T

Short Description Percut vertebroplasty thor Percut vertebroplasty lumb Percut vertebroplasty addl Percut kyphoplasty thor Percut kyphoplasty lumbar Percut kyphoplasty add-on Perq verte/sacroplsty fluor Perq verte/sacroplsty ct Perq sacral augmt unilat inj Perq sacral augmt bilat inj

Sacroiliac joint arthrodesis Sacroiliac joint fusion, including minimally invasive and percutaneous sacroiliac joint fusion, for the treatment of chronic low back pain is considered to be not medically necessary and is not covered. The agency will consider requests for exception to rule for severe traumatic injury. CPT Code 27280

Short Description Arthrodesis, sacroiliac joint (including obtaining graft)

Robotic assisted surgery Although robotic assisted surgery (RAS) may be considered medically necessary, the agency does not pay separately for HCPCS code S2900 and reimburses only for the underlying procedure. When billing for the underlying procedure, the agency requests billing providers to include RAS on the claim in order to track utilization and outcome. The agency will monitor RAS through retrospective auditing of billing and the review of operative reports.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Nervous system Discography The following procedures require prior authorization from the agency for clients age 21 and older. Prior authorization is not required for clients age 20 and younger. Discography for clients with chronic low back pain and uncomplicated lumbar degenerative disc disease is considered not medically necessary. Conditions which may be considered for authorization by the agency include:       

Radiculopathy. Functional neurologic deficits (motor weakness or EMG findings of radiculopathy). Spondylolisthesis (> Grade 1). Isthmic spondylolysis. Primary neurogenic claudication associated with stenosis. Fracture, tumor, infection, inflammatory disease. Degenerative disease associated with significant deformity.

CPT Code 62290 62291 72285 72295

Short Description Inject for spine disk x-ray Inject for spine disk x-ray Discography cerv/thor spine X-ray of lower spine disk

Facet neurotomy, cervical and lumbar Facet neurotomy requires a medical necessity review by Qualis Health. The agency has instructed Qualis Health to use Washington State’s Labor & Industries (L&I) Medical Treatment Guidelines (MTG) to establish medical necessity with the following exceptions:

A trial of conservative treatment modalities have been tried and failed for a minimum of three months, instead of six months, including all of the following:   

Medications: NSAIDS, muscle relaxants, corticosteroids, antidepressants, anticonvulsants or opiates Activity modification Physical therapy

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Implantable infusion pumps or implantable drug delivery systems The agency pays for CPT codes 62350, 62351, 62360, and 62361 when medically necessary and only for the indications below:  

Cancer pain Spasticity Note: Implantable drug delivery systems (Infusion Pump or implantable drug delivery system) are not considered medically necessary for treatment of chronic pain not related to cancer.

Spinal cord stimulation for chronic neuropathic pain The agency does not recognize spinal cord stimulation for chronic neuropathic pain as medically necessary. The agency will consider requests for other diagnoses. CPT codes 64575, 64580, 64581, 64585 and 64595 require prior authorization (PA) through the agency.

Spinal injections for diagnostic or therapeutic purposes (outpatient) The agency requires medical necessity reviews for spinal injection procedures, including diagnostic selective nerve root block through Qualis Health, which uses an established online questionnaire. (See Qualis Health in this guide for additional information.)

Diagnostic selective nerve root block The agency requires a medical necessity review for the diagnostic selective nerve root block through Qualis Health.

Sacroiliac joint injections For this procedure, the following policy applies:   

The patient has chronic sacroiliac joint pain. There must be a failure of at least 6 weeks of conservative therapy. These injections must be done with fluoroscopic or CT guidance

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Restrictions: 

There must be no more than 1 injection without medical record documentation of at least 30% improvement in function and pain, when compared to the baseline documented before the injections started.



Requests for more than 2 injections require clinical review.

Therapeutic/diagnostic epidural injections in the cervical, thoracic or lumbar spine Therapeutic/diagnostic epidural injections in the cervical, thoracic or lumbar spine are considered medically necessary for the treatment of chronic pain when the following criteria are met: 

Radicular pain (such as, back pain radiating below the knee, with or without positive straight leg raise) with at least 6 weeks of failed conservative therapy



Radiculopathy (such as motor weakness, sensory low or reflex changes) with at least 2 weeks of failed conservative therapy



The medical record with objective documentation of patient’s baseline level of function and pain



An injection that is given with anesthetic agent and/or steroid agent



An injection that is transforaminal, translaminar or interlaminar



Use of fluoroscopic, CT or ultrasound guidance

Restrictions: 

Prior authorization is required for the first injection, which will cover the second injection, if indicated. Additional authorization is required for the third injection.



No more than 2 injections (2 dates of service) may be given without medical record documentation of a 30% improvement in function and pain when compared to the baseline documented before the injections started. Function and pain must be measured and documented on a validated instrument.



There is a maximum of 3 injections within 6 months, and no more than 3 injections per a 12-month period. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

There should be no more than 2 vertebral levels and only one side injected (right or left) per date of service.



The MRI/CT scan is not a prerequisite for authorization of an epidural injection.

Transcutaneous electrical nerve stimulation (TENS) device The agency does not cover TENS devices, related supplies and services for independent homeuse.

Vagus nerve stimulation (VNS) (WAC 182-531-0200(h)) The agency considers VNS for the treatment of epilepsy as medically necessary only for management of epileptic seizures in patients age 12 and older who have a medically refractory seizure disorder. VNS procedures can be performed in an inpatient hospital or outpatient hospital setting. The agency requires prior authorization for VNS (CPT codes 61885, 61886, 64568, 64569, 64570). Prior authorization is not required for VNS programming (CPT codes 95970, 95974, and 95975) performed by a neurologist. The agency does not pay for VNS and related procedures for a diagnosis of depression (CPT 64553-64565, 64590-64595, 95970, 95974, and 95975). VNS for the treatment of depression has no evidence to support coverage.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Sleep apnea Surgical treatment for sleep apnea The agency requires prior authorization for the following surgical treatment for obstructive sleep apnea (OSA) or upper airway resistance syndrome (UARS) when billed with diagnosis code G47.33 (obstructive sleep apnea) or A81.9 (unspecified sleep apnea): Procedure Codes 21199 21685 42120 42140 42145 42160 42299

Short Descriptions Reconstr lwr jaw w/advance Hyoid myotomy & suspension Remove palate/lesion Excision of uvula Repair palate pharynx/uvula Treatment mouth roof lesion Palate/uvula surgery

See also Sleep Medicine Testing.

Urinary systems Collagen implants The agency pays for CPT code 51715 and HCPCS codes L8603, L8604 and/or L8606 only when the appropriate diagnosis code N36.42 or N36.43 (Intrinsic sphincter deficiency) is used. See Medical Supplies and Equipment – Urinary Tract Implants for limitations.

Indwelling catheter 

Separate payment is allowed for insertion of a temporary, indwelling catheter when it is used to treat a temporary obstruction and is performed in a physician's office.



Bill for the insertion of the indwelling catheter using CPT code 51702 or 51703.



The agency pays providers for insertion of an indwelling catheter only when performed in an office setting.



Insertion of an indwelling catheter is bundled when performed on the same day as a major surgery. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Insertion of an indwelling catheter is bundled when performed during the postoperative period of a major surgery.

Urinary tract implants (CPT code 51715) Prior to inserting a urinary tract implant, the provider must: 

Have urology training in the use of a cystoscope and must have completed a urinary tract implant training program for the type of implant used.



Document that the client has shown no incontinence improvement through other therapies for at least 12 months prior to collagen therapy.



Administer and evaluate a skin test for collagen sensitivity (CPT code 95028) over a four-week period prior to collagen therapy. A negative sensitivity must be documented in the client's record.

Refer to urinary tract implants covered by the agency. All services provided and implant codes must be billed on the same claim form.

Urological procedures with sterilizations in the description These procedures may cause the claim to stop in the agency's payment system and trigger a manual review as a result of the agency's effort to remain in compliance with federal sterilization consent form requirements. If the surgery is not being done for the purpose of sterilization, or the sterilizing portion of the procedure is not being performed, a sterilization consent form is not required. However, one of the following must be noted in the Comments section of the claim:  

Not sterilized Not done primarily for the purpose of sterilization

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Radiology Services (WAC 182-531-1450)

Radiology services – general limits 

The agency does not pay radiologists for after-hours service codes.



Claims must have the referring provider’s national provider identifier (NPI) in the appropriate field on the claim form.



The following services are not usually considered medically necessary and may be subject to post-pay review:   

X-rays for soft tissue diagnosis Bilateral X-rays for a unilateral condition X-rays in excess of two views

Note: The agency does not pay for radiology services with diagnosis code V72.5. Providers must bill the appropriate medical ICD diagnosis code.

Radiology modifiers for bilateral procedures 

Bill the procedure on two separate lines using modifier 50 on one line only. In addition, include modifier LT or RT on the separate lines when the radiological procedure is performed on both sides.



Do not use modifier 50, LT, or RT if the procedure is defined as bilateral.

Breast, Mammography Mammograms The agency has adopted the National Cancer Institute (NCI) recommendations regarding screening mammograms (procedure codes 77052, 77057, and G0202). For clients age 40 and over, one annual screening mammogram is allowed per calendar year. Screening mammograms, with or without tomosynthesis, for clients age 39 and younger require prior authorization. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services The agency covers digital breast tomosynthesis (DBT) (CPT code 77063) when performed with a screening mammography (HCPCS G0202) for clients age 40 through 74 who are candidates for screening mammography. One annual screening is allowed per calendar year. See the agency’s Physician-Related/Professional Services fee schedule for specific code details.

Diagnostic Radiology (Diagnostic Imaging) Multiple procedure payment reduction (MPPR) The agency applies the multiple payment model outlined by the Centers for Medicare and Medicaid Services (CMS) for multiple diagnostic radiology procedures. See MLN Matters® Number: MM6993. The MPPR applies to the technical component (TC) of certain diagnostic imaging procedures when billed for the same client, on the same day and session, by the same billing provider. The MPPR applies to:  

TC only services. TC portion of global services for the procedures with multiple surgery value of ‘4’ in the Medicare Physicians Fee Schedule Database.

The MPPR does not apply to:  

The professional component (PC). The PC portion of global services.

The agency’s payment is as follows:  

A full payment for the highest priced TC radiology code on the claim A 50% reduction applied to each subsequent TC radiology code on the same claim

Which procedures require a medical necessity review by Qualis Health? (WAC 182-531-1450) The agency requires prior authorization for selected procedures The agency and Qualis Health have contracted to provide web-based submittal for utilization review services to establish the medical necessity of selected procedures. Qualis Health conducts the review of the request to establish medical necessity, but does not issue authorizations. Qualis CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Health forwards its recommendations to the agency for final authorization determination. See Medical Necessity Review by Qualis Health for additional information.

Head Abdomen Pelvis Abdomen& Pelvis 

Computed Tomography (CT) 70450 70460 74150 74160 72192 72193 74176 74177

70470 74170 72194 74178

Multiple CT Scans are allowed only if done at different times of the day or if modifiers LT or RT are attached. Magnetic Resonance Imaging (MRI) Head C – Spine L- Spine Upper Extremity Breast Lower Extremity

70551 72141 72148 73221 77058 C8904* C8907* 73721

70552 72142 72149 73222 77059 C8905* C8908* 73722

70553 72156 72158 73223 C8903* C8906* 73723

*Required for outpatient hospital claims

Reminder for outpatient hospitals: When requesting a medical necessity review by Qualis Health for a breast MRI, use the 7xxxx CPT® code. However, when billing Medicaid, use the “C” HCPCS code. Advanced imaging services do NOT require prior authorization when billed with either of the following place of service (POS):  

(POS) 21 (Inpatient Hospital) (POS) 23 (Emergency Room)

When billing for a professional component performed in a POS other than POS 21 or 23 such as a radiologist’s office, but the image was performed on a client who was in the ER or an inpatient setting, use modifier 26 and enter “ER ordered service,” or “client inpatient,” or “client referred from ER,” or “professional read only for image not done by our facility,” or “professional services only for pre-authorized service” as follows: Paper Billers Box 19 on the CMS-1500 form

Electronic billers In the Comments section

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Physician-Related Services/Health Care Professional Services A radiologist who performed a professional interpretation, referred to as a “read- only,” on an outpatient advanced image must be added to the agency’s authorization record to receive payment. 

Contact the agency at 800-562-3022, ext. 52018, to add the reading radiologist’s NPI to the record. -



OR –

Submit a written request for an NPI add/update as follows: 

Go to Document Submission Cover Sheets.



Scroll down and click on number 7. PA (Prior Authorization) Pend Forms.



When the form appears on the screen, insert the Authorization Reference number (ProviderOne authorization number) in the space provided and press enter to generate the barcode on the form.

Note: Professionals who do “read-only” when another facility ordered and performed the advanced imaging, but did not obtain prior authorization, must add: “Professional read only for image not done by my facility” in the comments field of the claim.

Imaging for rhinosinusitis Imaging for rhinosinusitis is covered and requires a medical necessity review by Qualis Health. Imaging of the sinus for rhinosinusitis using x-ray or ultrasound is not covered. Imaging with sinus computed tomography (CT) is covered for rhinosinusitis when: 

The client is experiencing the following “red flags”:  Swelling of orbit  Altered mental status  Neurological findings  Signs of meningeal irritation  Severe headache  Signs of intracranial complication, including, but not limited to:  Meningitis,  Intracerebral abscess  Cavernous sinus thrombosis  Involvement of nearby structures, including, but not limited to periorbital cellulitis CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services  Two of the following persistent symptom for more than 12 weeks AND medical therapy has failed:  Facial pain-pressure-fullness  Mucopurulent drainage  Nasal obstruction (congestion)  Decreased sense of smell 

Needed for surgical planning.

Magnetic resonance imaging (MRI) of the sinus is covered when the criteria in this section are met AND the client is younger than age 18 or is pregnant. Repeat scanning (CT or MRI) is covered for “red flags” or surgical planning only.

Computed tomography angiography (CTA) CPT code 75574 is restricted to place of service 19, 21, 22, 23. The agency pays for CTA when:  

Using computed tomography machines with 64-slice or better capability AND The following medical necessity criteria are met:  

Patients have low to intermediate risk of coronary artery disease Investigation of acute chest pain is conducted in an emergency department or hospital setting

The agency will not pay for CTA when:  

Using a CT scanner that uses lower than 64-slice technology OR The procedure is not medically necessary as follows:  

Patients are asymptomatic or at high risk of coronary artery disease. Investigation of coronary artery disease is conducted outside of the emergency department or hospital setting.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Contrast material (WAC 182-531-1450(2)) Contrast material is not paid separately, except in the case of low-osmolar contrast media (LOCM) used in intrathecal, intravenous, and intra-arterial injections for clients with one or more of the following conditions: 

A history of previous adverse reaction to contrast material, with the exception of a sensation of heat, flushing, or a single episode of nausea or vomiting



A history of asthma or allergy



Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension



Generalized severe debilitation



Sickle cell disease

To bill for LOCM, use the appropriate HCPCS procedure codes: Q9951, Q9965, Q9966 or Q9967. The brand name of the LOCM and the dosage must be documented in the client's record.

Consultation on X-ray examination When billing a consultation, the consulting physician must bill the specific X-ray code with modifier 26 (professional component). For example: The primary physician would bill with the global chest X-ray (CPT code 71020), or the professional component (CPT code 71020-26), and the consulting physician would bill only for the professional component of the chest X-ray (e.g., CPT code 71020-26).

Coronary artery calcium scoring The agency does not recognize computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium as medically necessary. Prior authorization from the agency is required for CPT code 75571.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Magnetic resonance imaging (MRI) 

Check the Physician’s Related Services fee schedule for authorization requirements for MRIs.



The agency is implementing the Washington State Health Technology Clinical Committee (HTCC's) decision that uMRI (upright MRI) is experimental and investigational; therefore, according to WAC 182-501-0165, uMRI is a "D" level evidence that is not supported by any evidence regarding its safety and efficacy. Medicaid will not reimburse unless one of the following criteria is met:  

The client must have a humanitarian device exemption. There must be a local Institutional Review Board protocol in place.

Portable X-rays 

Portable X-ray services furnished in a client’s home or nursing facility and payable by the agency are limited to the following:  Skeletal films involving extremities, pelvis, vertebral column, or skull  Chest or abdominal films that do not involve the use of contrast media  Diagnostic mammograms



Bill for transportation of X-ray equipment as follows: 

R0070 - If there is only one patient bill one unit



R0075 - If there are multiple patients, bill one unit per individual client’s claim with one of the following modifiers, as appropriate. Bill using a separate claim form for each Medicaid client seen. The agency pays the fee for procedure code R0075 divided by the number of clients, as outlined by the modifiers in the following table: Procedure Code R0070 R0075-UN R0075-UP R0075-UQ R0075-UR R0075-US

Short Description Transport portable x-ray Transport port x-ray multipl-2 clients seen Transport port x-ray multipl-3 clients seen Transport port x-ray multipl-4 clients seen Transport port x-ray multipl-5 clients seen Transport port x-ray multipl-6 or more clients seen

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Note: The agency’s payment for procedure codes R0070 and R0075 includes setup. The fee for HCPCS code R0075 is divided among the clients served, as outlined by the modifiers indicated above. If no modifiers are used for HCPCS code R0075, the code will be denied. Do not bill HCPCS code R0070 in combination with HCPCS code R0075.

Ultrasound screening for abdominal aortic aneurysm (HCPCS G0389) The agency covers ultrasound screening for abdominal aortic aneurysm only when both of the following apply: 

Billed with diagnosis code Z13.6 (special screening for other and unspecified cardiovascular conditions)



A client meets at least one of the following conditions:  

Has a family history of an abdominal aortic aneurysm Is a male who is between 65 and 75 years old and has smoked at least 100 cigarettes in his lifetime

Virtual colonoscopy or computed tomographic colonography The agency does not recognize computed tomographic colonography for routine colorectal cancer screening as medically necessary. CPT Code 74261 74262 74263

Description Ct colonography dx Ct colonography dx w/dye Ct colonography screening

Screening & Monitoring Tests for Osteopenia/Osteoporosis The agency covers bone mineral density testing and repeat testing with dual x-ray absorptiometry (DXA) with limitations. These tests require expedited prior authorization. See EPA #870001363 and EPA #870001364 for criteria. If the EPA criteria are not met, prior authorization is required. Note: Serial monitoring is not covered once treatment for osteoporosis has begun.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Functional neuroimaging for primary degenerative dementia or mild cognitive impairment The agency does not cover functional neuroimaging for primary degenerative dementia or mild cognitive impairment.

Diagnostic Ultrasound Obstetrical ultrasounds Routine ultrasounds for average risk pregnant women are considered medically necessary with limitations. The agency considers two ultrasounds per average risk singleton pregnancy as medically necessary. The agency pays for: 

One routine ultrasound in the first trimester (less than 13 weeks gestational age) for the purpose of:   



Identifying fetal aneuploidy Anomaly Dating confirmation

One routine ultrasound for the purpose of anatomy screening between 16 and 22 weeks gestation.

The agency does not pay for:  

Ultrasounds when provided solely for the determination of gender. Third trimester ultrasounds unless a specific indication has developed or the pregnancy is considered high-risk.

The above conditions and limitations do not apply to multiple gestation pregnancies and/or fetus with aneuploidy or known anomaly. Note: Additional ultrasounds are subject to postpayment review.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Nuclear Medicine The agency requires prior authorization for selected procedures.

Which procedures require a medical necessity review from the agency? (CPT code 78459) The agency requires prior authorization for myocardial PET imaging for metabolic evaluation.

Which procedures require a medical necessity review by Qualis? (WAC 182-531-1450) The agency and Qualis Health have contracted to provide web-based submittal for utilization review services to establish the medical necessity of selected procedures. Qualis Health conducts the review of the request to establish medical necessity, but does not issue authorizations. Qualis Health forwards its recommendations to the agency for final authorization determination. See medical necessity review by Qualis Health for additional information. Cardiac Imaging (SPECT) Ht muscle image spect sing Ht muscle image spect mult Ht muscle image planar sing Ht musc image planar mult PET Scans Brain

78608

Limited Area Skull base to mid thigh Full Body

78811 78812 78813

78451 78452 78453 78454 PET-CT Scans Limited Area (Chest, head, neck) Skull base to mid thigh Whole body

78814 78815 78816

Advanced imaging services do NOT require PA when billed with either of the following place of service (POS):  

(POS) 21 (Inpatient Hospital) (POS) 23 (Emergency Room)

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Physician-Related Services/Health Care Professional Services

When billing for a professional component performed in a POS other than POS 21 or 23 such as a radiologist’s office, but the image was performed on a client who was in the ER or an inpatient setting, enter “ER Ordered Service” or “client inpatient” as follows: Paper Billers Box 19 on the CMS-1500 form

Electronic billers In the Comments section

A radiologist who performed a professional interpretation, referred to as a “read- only”, on an outpatient advanced image must be added to the agency’s authorization record to receive payment. Contact the agency at 800-562-3022, ext. 52018, to add the reading radiologist’s NPI to the record. Note: Professionals who do read-only when another facility ordered and performed the advanced imaging, but did not obtain prior authorization, must add: “Professional read only for image not done by my facility” in the comments field of the claim.

Radiopharmaceutical diagnostic imaging agents 

When performing nuclear medicine procedures, separate payment is allowed for radiopharmaceutical diagnostic imaging agents (HCPCS Q9945-Q9951).



The agency allows the following CPT codes for radiopharmaceutical therapy without PA: CPT codes 79101, 79445, and 79005.

Nuclear medicine - billing When billing the agency for nuclear medicine, the multiple surgery rules are applied when the coding combinations listed below are billed: 

For the same client, on the same day, by the same physician or by more than one physician of the same specialty in the same group practice



With other codes that are subject to the multiple surgery rules, not just when billed in the combinations specified below:  CPT code 78306 (bone imaging; whole body) and CPT code 78320 (bone imaging; SPECT)  CPT code 78802 (radionuclide localization of tumor; whole body), CPT code 78803 (tumor localization; SPECT), and CPT code 78804 (radiopharmaceutic localization of tumor requiring 2 or more days) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

 CPT code 78806 (radionuclide localization of abscess; whole body) and 78807 (radionuclide localization of abscess; SPECT)

Radiation Oncology Intensity modulated radiation therapy (IMRT) IMRT is considered medically necessary for the treatment of: 

Head and neck cancers  See EPA #870001313  All other diagnoses not listed in the EPA require prior authorization.



Prostate cancer  See EPA #870001313



To spare adjacent critical structures to prevent toxicities within expected life span  See EPA #870001374



Undergoing treatment in the context of evidence collection/submission of outcome data 

Prior authorization required

Procedure Code 77301 77338 77370 77385 77386 G6016

Short Description Radiotherapy dose plan imrt Design mlc device for imrt Radiation physics consult Ntsty modul rad tx dlvr smpl Ntsty modul rad tx dlvr cplx Delivery comp imrt

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Proton beam radiation therapy The following procedure codes for proton beam radiation therapy require prior authorization (PA): Procedure Code Short Description PA 77520 Proton trmt simple w/o comp Yes 77522 Proton trmt simple w/comp Yes 77523 Proton trmt intermediate Yes 77525 Proton treatment complex Yes

Limitations of Coverage Proton beam therapy is a covered benefit for the following conditions:    

Ocular cancers Pediatric cancers (e.g., medulloblastoma, retinoblastoma, Ewing’s sarcoma) Central nervous system tumors Other non-metastatic cancers when the patient has had prior radiation in the expected treatment field with contraindication to all other forms of therapy

Stereotactic Radiation Surgery Stereotactic Radiation Surgery (SRS) for Central Nervous System (CNS) primary and metastatic tumors require prior authorization. The agency pays for SRS for adults and children when both of the following criteria are met:

 Patient functional status score (i.e., Karnofsky score) is greater than or equal to 50  Evaluation includes multidisciplinary team analysis (e.g., tumor board), including surgical input

Stereotactic Body Radiation Therapy Stereotactic Body Radiation Therapy (SBRT) is covered for adults and children for the following conditions only:  

For cancers of spine/paraspinal structures For inoperable non-small cell lung cancer, stage 1

Evaluation includes multidisciplinary team analysis (e.g., tumor board), including surgical input. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Pathology and Laboratory (WAC 182-531-0800 and WAC 182-531-0850)

Certifications Independent laboratories - certification Independent laboratories must be certified according to Title XVII of the Social Security Act (Medicare) to receive payment from Medicaid. The agency pays laboratories for Medicareapproved tests only.

Reference labs and facilities - CLIA certification All reference (outside) labs and facilities performing laboratory testing must have a Clinical Laboratory Improvement Amendment (CLIA) certificate and identification number on file with the agency in order to receive payment from the agency. To obtain a CLIA certificate and number, or to resolve questions concerning a CLIA certification, call (206) 361-2805 or write to: DOH - Office of Laboratory Quality Assurance 1610 NE 150th Street Shoreline, WA 98155 (206) 361-2805 (phone); (206) 361-2813 (fax)

Anatomic Pathology Pap smears For professional services related to Pap smears, refer to Cancer Screens. 

Use CPT® codes 88147-88154, 88164-88167, and HCPCS P3000-P3001 for conventional Pap smears.



The agency pays for thin layer preparation CPT codes 88142-88143 and 88174-88175. The agency does not pay providers for HCPCS codes G0123-G0124 and G0141-G0148. The agency pays for thin layer Pap smears at Medicare's payment levels. Thin layer preparation and conventional preparation CPT codes cannot be billed in combination. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Use CPT codes 88141 and 88155 in conjunction with codes 88142-88143 and 8816488167.



Use the appropriate medical diagnosis if a condition is found.



The agency pays providers for a routine Pap smear according to nationally recognized clinical guidelines. For clients on the TAKE CHARGE or Family Planning Only programs, use diagnosis codes from the Z30 series diagnosis codes, excluding Z30.012.



The agency does not pay providers for CPT code 88112 with the appropriate diagnosis code Z01.411, Z01.419, or Z12.4.

Screening exams Cancer screens (HCPCS codes G0101, G0103-G0105, G0121-G0122, S8032, and CPT code 82270) The agency covers the following cancer screenings:    

   

Cervical or vaginal Colonoscopies Colorectal Lung (low dose CT)

HCPCS Code G0101 G0103 G0104

Short Description CA screen; pelvic/breast exam PSA screening

Pelvic/breast exams Prostate PSA testing Screening sigmoidoscopies

Limitations Females only; As indicated by nationally recognized clinical guidelines. [Use for Pap smear professional services] Once every 12 months when ordered for clients age 50 and older Clients age 50 and older who are not at high risk Once every 48 months Clients at high risk for colorectal cancer One every 24 months N/A Clients age 50 and older Once every 10 years Clients age 50 and older Once every 5 years Requires EPA (see EPA #870001362). If the client does not meet EPA criteria, PA is required (see Prior Authorization)

CA screen; flexi sigmoidscope G0105* Colorectal scrn; hi risk ind 82270 Occult blood, feces G0121* Colon CA scrn; not high risk ind G0122 Colon CA scrn; barium enema S8032 Low-dose computed tomography for lung cancer screening *Note: Per Medicare guidelines, the agency’s payment is reduced when billed with modifier 53 (discontinued procedure).

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Disease organ panels--automated multi-channel tests The agency pays for CPT lab panel codes 80047, 80048, 80050, 80051, 80053, 80061, 80069, and 80076. The individual automated multi-channel tests are: Procedure Code 82040 82247 82248 82310 82330 82374 82435 82465 82565 82947 82977 83615 84075 84100 84132 84155 84295 84450 84460 84478 84520 84550 85004 85007 85009 85027

Short Description Albumin; serum Bilirubin; total Bilirubin; direct Calcium; total Calcium, ionized Carbon dioxide (bicarbonate) Chloride; blood Cholesterol, serum, total Creatine; blood Glucose; quantitative Glutamyltransferase, gamma (GGT) Lactate dehydrogenase (LD) (LDH) Phosphatase, alkaline Phosphorous inorganic (phosphate) Potassium; serum Protein; total, except refractometry Sodium; serum Transferase; apartate amino (AST)(SGOT) Transferase; alanine amino (AST)(SGPT) Tryglycerides Urea nitrogen; quantitative Uric acid; blood Automated diff wbc count B1 smear w/diff wbc count Manual diff wbc count b-coat Complete cbc, automated



Providers may bill a combination of panels and individual tests not included in the panel. Duplicate tests will be denied. Providers may not bill for the tests in the panel separately per the National Correct Coding Initiative (NCCI).



Each test and/or panel must be billed on a separate line.



All automated/nonautomated tests must be billed on the same claim form when performed for a client by the same provider on the same day.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Fetal fibronectin The semiquantitative measurement of fetal fibronectin may be considered as medically necessary with all of the following conditions: 

Singleton or multiple gestation pregnancies



Intact amniotic membranes



Cervical dilation <3 cm



Signs or symptoms suggestive of preterm labor (such as, regular uterine contractions, cramping, abdominal pain, change in vaginal discharge, vaginal bleeding, pelvic pressure, and/or malaise)



Sampling that is performed between 24 weeks 0 days and 34 weeks 6 days of gestation



Results available in less than 4 hours, for the test results to impact immediate care decisions for the pregnant client

The use of fetal fibronectin assays is considered to be not medically necessary for the following indications: 

No symptoms of preterm birth (there is no clinical evidence that treating women with no labor symptoms or high risk for premature delivery benefits mother or baby)



Routine screening or determination of risk of preterm delivery in asymptomatic women



Outpatient tests and the woman awaits test results at home



Monitoring of asymptomatic women at high-risk for preterm labor (PTL)



Women not requiring induction due to likelihood of delivery within 24 to 48 hours



Ruptured membranes or advanced cervical dilation (3 cm or more)



Imminent birth

For all other indications, there is insufficient evidence to permit conclusions on efficacy and net health outcomes. CPT Code 82731

Short Description Fetal fibronectin, cervicovaginal secretions, semi-quantitative

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

ICD diagnoses codes that support medical necessity are: ICD Diagnoses Code Short Description N88.3 Incompetence of cervix See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Complications mainly related to pregnancy Services/Health Care Professionals. Cervical incompetence during pregnancy, childbirth and the O34.32, O34.33 puerperium O36.8190 Decreased fetal movement Other indications for care or intervention related to labor and O09.40, O09.529 delivery R10.9 Abdominal pain

Noninvasive prenatal diagnosis of fetal aneuploidy using cell-free fetal nucleic acids in maternal blood (NIPT) The agency pays for noninvasive prenatal diagnosis of fetal aneuploidy using cell-free fetal nucleic acids in maternal blood (NIPT) (CPT code 81507) when it is medically necessary. Expedited prior authorization (EPA) is required. See EPA#870001344.

Vitamin D screening and testing (CPT code 82306, 82652) Routine Vitamin D screening for the general population (CPT codes 82306, 82652) is not considered medically necessary. Vitamin D testing (25-hydroxyvitamin D, calcidiol, CPT code 82306) may be considered medically necessary for the following conditions:       

Chronic kidney disease stage 3 or greater End stage renal disease Evaluation of hypo- or hypercalcemia Hypocalcemia and hypomagnesemia of newborn Hypophosphatemia Hypoparathyroidism Intestinal malabsorption including:  Blind loop syndrome  Celiac disease  Pancreatic Steatorrhea CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services     

Secondary hyperparathyroidism Hypervitaminosis D Osteomalacia Osteopenia Rickets



In the setting of other laboratory or imaging indicators of vitamin D deficiency for:  Calculus of kidney or ureter  Chronic liver disease in the absence of alcohol dependency  Protein-calorie malnutrition

Vitamin D testing (1,25-dihydroxyvitamin D, calcitriol, CPT 82652) may be considered medically necessary as a second tier test for the following conditions:       

Disorders of calcium metabolism Familial hypophosphatemia Fanconi syndrome Hypoparathyroidism or hyperparathyroidism Vitamin D resistant rickets Tumor induced osteomalacia Sarcoidosis

CPT Code

Short Description

82306

Vitamin d 25 hydroxy

82652

Vit d 1 25-dihydroxy

ICD Diagnosis Code See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals

Drug Testing The agency pays for drug screens when both of the following apply: 

The screen is medically necessary and ordered by a physician as part of a medical evaluation.



The drug or alcohol screen is required to assess suitability for medical tests or treatment being provided by the physician.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Drug screening for medication assisted treatment (MAT) Drug assay tests are covered for Washington Apple Health clients receiving medication assisted treatment (MAT) for substance use disorders under the following conditions. The agency will reimburse up to 24 tests in a 12-month period. For presumptive testing, use the following G codes:  G0477, G0478, and G0479 (Only one of the three presumptive G codes may be billed per client per day.) For definitive drug testing, use the following G codes:  G0480, G0481, G0482 and G0483 (Only one of the four definitive G codes may be billed per client per day.) For definitive testing, the unit used to determine the appropriate definitive G code to bill is “drug class.” Each drug class may only be used once per day in determining the appropriate definitive G code to bill. Drug classes are listed in the CPT Manual. The CPT Manual may be consulted for examples of individual drugs within each class. The following testing codes will no longer be reimbursed:  G0431, G0434  HCPCS codes G6030 through G6058  80300 – 80377

(Monitoring for patients who are on chronic opioid therapy for the treatment of chronic noncancer pain should follow the Agency Medical Director’s Group 2015 Interagency Guideline on Prescribing Opioids for Pain, Appendix D). (These guidelines do not pertain to urine drug testing required for employment, emergency department evaluation or those related to criminal justice requirements). For monitoring patients receiving (MAT), drug assay tests are considered medically necessary in the following instances: Screening, presumptive, or in office testing with point of care immunoassays (IA) is considered medically necessary to:   

Confirm the use of prescribed substances Identify the presence of illicit or non-prescribed substances Prior to starting a patient on MAT for a substance use disorder

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Physician-Related Services/Health Care Professional Services Confirmatory or definitive testing with gas chromatography–mass spectrometry (GCMS) or liquid chromatography-tandem mass spectrometry (LCMS) is considered medically necessary to interpret the findings on presumptive testing when there is a discrepancy between patient report, the test and what is being prescribed: For example:  

To confirm the presence of an unexpected or non-prescribed drug identified by an IA To confirm that a prescribed drug or its metabolite not present on the IA are in fact being taken

In addition, confirmatory testing should only be ordered and performed on a patient/drug specific basis. Clinical documentation must support why a particular drug or class was tested for and document a follow up plan based on the test results. Note: The agency requires prior authorization for the use of presumptive or confirmatory testing panels that test substances or drug groups not listed below. Clinical documentation supporting the rationale for the particular tests being ordered is required.

Drugs or drug classes and their metabolites automatically approved:                     

Alcohols Alcohol biomarkers Alkaloids, not otherwise specified Amphetamines Anabolic steroids Analgesics, non-opioid Antidepressants, serotonergic class Antidepressants, tricyclic and other cyclicals Antidepressants, not otherwise specified Antiepileptics, not otherwise specified Antipsychotics, not otherwise specified Barbiturates Benzodiazepines Buprenorphine Cannabinoids, natural Cannabinoids, synthetic Cocaine Fentanyls Gabapentin, non-blood Heroin metabolite Ketamine and Norketamine Methadone CPT® codes and descriptions only are copyright 2015 American Medical Association

137

Physician-Related Services/Health Care Professional Services               

Methylenedioxyamphetamines Methylphenidate Opiates Opioids and opiate analogs Oxycodone Phencyclidine Pregabalin Propoxyphene Sedative Hypnotics (nonbenzodiazepines) Skeletal muscle relaxants Stereoisomer (enantiomer) analysis Stimulants, synthetic Tapentadol Tramadol Drugs or substances, definitive, qualitative or quantitative, not otherwise specified

The CPT Manual may be consulted for examples of individual drugs within each class. Serial quantitative monitoring of drugs or drug metabolite levels is not considered medically necessary. Periodic reviews of ordering patterns will be performed to look for and contact practices that appear to be outliers compared to their peers. Additional information when prescribing (Suboxone®) The provider must have FDA approval to prescribe buprenorphine/naloxone (Suboxone®) for opioid use disorders (OUD). The provider must have a CLIA waiver if confirmatory testing is performed at the site of practice. Enter the following information on the claim forms:  

“Certified bupren provider” in the Comments field ICD diagnosis codes F11.20 – F11.288 on:   

The 837P claim form The Claims notes field on the DDE professional claim Field 19 on the CMS-1500 claim form (version 02/12)

More information regarding CLIA certification can be found on the U.S. Food and Drug Administration website. CPT® codes and descriptions only are copyright 2015 American Medical Association

138

Physician-Related Services/Health Care Professional Services The agency has adopted the Agency Medical Directors’ Group (AMDG) drug screening guidelines outlined in the Agency Medical Directors’ Interagency Guidelines. For more information, go online at:  

Interagency Guidelines on Opioid Dosing for Chronic Non-Cancer Pain Opioid Guidelines and DOH Pain Management Rules Recommended Urine Drug Testing Frequency

Risk Category Low Risk by Opiate Risk Tool (ORT)

Periodic (e.g., up to one time per year)

Moderate Risk by ORT

Regular (e.g., up to two times per year)

High Risk by ORT or opioid doses >120 MED/d

Frequent (e.g., up to three times per year)

Aberrant Behavior (lost prescriptions, multiple At the time of visit (address aberrant requests for early refill, opioids from multiple behavior in person, not by telephone) providers, unauthorized dose escalation, apparent intoxication) The agency does not pay for either of the following:  

Routine drug screening panels Monitoring for program compliance in either a residential or outpatient drug or alcohol treatment program Note: Labs must offer single drug testing. Drug screening must be medically indicated and the reason for the specific drug screening must be documented in the client record. Lab slips must be signed by the prescribing provider.

When monitoring a client for drug/alcohol use, refer the client to a Division of Behavioral Health and Rehabilitation (DBHR)-approved program for evaluation and treatment. Clients served by these programs may receive drug/alcohol screening according to an established treatment plan determined by their treating provider. For clients in the DBHR-contracted methadone treatment programs and pregnant women in DBHR-contracted treatment programs, drug screens are paid through a contract issued to one specific laboratory by DBHR, not through the agency.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Suboxone when used for pain control The agency pays for drug screens when both of the following apply: 

They are medically necessary and ordered by a physician as part of a medical evaluation.



The drug and/or alcohol screens are required to assess suitability for medical tests or treatment being provided by the physician.

See the agency’s Physician-Related Fee Schedule for covered drug screening codes.

Immunology HIV testing The agency pays providers for HIV testing as recommended in the CDC guidelines.

Targeted TB testing with interferon-gamma release assays Targeted TB testing with interferon-gamma release assays may be considered medically necessary for clients age five and older for one of the following conditions: 

History of positive tuberculin skin test or previous treatment for TB disease



History of vaccination with BCG (Bacille Calmette-Guerin)



Recent immigrants (within 5 years) from countries that have a high prevalence of tuberculosis



Residents and employees of high-risk congregate settings (homeless shelters, correctional facilities, substance abuse treatment facilities)



Clients with an abnormal chest X-ray (CXR) consistent with old or active TB



Clients undergoing evaluation or receiving TNF alpha antagonist treatment for rheumatoid arthritis, psoriatic arthritis, or inflammatory bowel disease

AND 

Client agrees to remain compliant with treatment for latent tuberculosis infection if found to have a positive test

The tuberculin skin test is the preferred method of testing for children under the age of 5. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

CPT Code 86480 86481

Short Description Tb test cell immun measure Tb ag response t-cell susp

Providers must follow the agency’s expedited prior authorization (EPA) process to receive payment for targeted TB testing. See EPA #870001325 in EPA Criteria Coding List.

Molecular Pathology Tests Genetic testing may be considered as medically necessary to establish a molecular diagnosis of an inheritable disease when all of the following are met: 

The client displays clinical features, or is at direct risk of inheriting the mutation in question (pre-symptomatic) based on family history, an analysis of genetic relationships and medical history in the family.



Diagnostic results from physical examination, pedigree analysis, and conventional testing are inconclusive.



The clinical utility of the test is documented in the authorization request, including how the test results will guide decisions concerning disease treatment, management, or prevention; AND these treatment decisions could not otherwise be made in the absence of the genetic test results.



Clients receive pre- and post-test genetic counseling from a qualified professional when testing is performed to diagnose or predict susceptibility for inherited diseases.

Genetic testing is considered not medically necessary if any of the above criteria are not met. Refer to the fee schedule for agency coverage of Tier 1 and Tier 2 molecular pathology procedures.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Companion Diagnostic Tests Companion diagnostic and certain pharmacogenetic tests may be considered as medically necessary by the agency. Prior authorization is required for the following tests: CPT Code 81210 8122081224 81235

Description BRAF V600E mutation G6551D mutation CFTR gene

81275

EGFR exon 19/21 deletion KRAS gene analysis

81275

KRAS gene analysis

81381

HLA-B*5701

ICD Diagnosis Codes

See the agency’s Program Policy Approved Diagnosis Codes for PhysicianRelated Services/ Health Care Professionals

Indication

Treatment

Melanoma stage IIIC or IV Cystic Fibrosis

Vemurafenib

Non-squamous NSCLC Colorectal cancer

Erlotinib Cetuximab

Colorectal cancer

Panitumumab

Hypersensitivity screening prior to initiation of Abacavir

Abacavir Sulfate

Ivacaftor

Organ and disease-oriented panels Automated multi-channel tests - payment For individual automated multi-channel tests, providers are paid on the basis of the total number of individual automated multi-channel tests performed for the same client, on the same day, by the same laboratory.   

When all the tests in a panel are not performed, each test must be billed as a separate line item on the claim form. When there are additional automated multi-channel tests not included in a panel, each additional test must be billed as a separate line item on the claim form. Bill any other individual tests as a separate line item on the claim form.

Payment calculation for individual automated laboratory tests is based on the total number of automated multichannel tests performed per day, per patient. Payment for each test is based on Medicare’s fees multiplied by the agency’s fiscal year laboratory conversion factor.

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Physician-Related Services/Health Care Professional Services For example: If five individual automated tests are billed, the payment is equal to the internal code’s maximum allowable fee. If five individual automated tests and a panel are billed, the agency pays providers separately for the panel at the panel’s maximum allowable. Payment for the individual automated tests, less any duplicates, is equal to the internal code’s maximum allowable fee. If one automated multi-channel test is billed, payment is at the individual procedure code or internal code’s maximum allowable fee, whichever is lower. The same applies if the same automated multi-channel test is performed with modifier 91.

Disease organ panel - nonautomated multi-channel Organ and disease panels (CPT codes 80055 and 80074) do not include automated multi-channel tests. If all individual tests in the panel are not performed, payment is the individual procedure code maximum allowable fee or billed charge, whichever is lower. The nonautomated multi-channel tests are: CPT Code 83718 84443 85025 85651 86255 86430 86592 86644 86694 86705 86709 86762 86777 86803 86850 86900 86901 87340

Short Description Assay of lipoprotein Assay thyroid stim hormone Automated hemogram Rbc sed rate, nonautomated Fluorescent antibody, screen Rheumatoid factor test Blood serology, qualitative CMV antibody Herpes simplex test Hep b core antibody, test Hep a antibody, igm Rubella antibody Toxoplasma antibody Hep c ab test, confirm RBC antibody screen Blood typing, ABO Blood typing, Rh(D) Hepatitis b surface ag, eia

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Billing Billing for laboratory services that exceed the lines allowed 

Providers who bill on hardcopy CMS-1500 claim forms (version 02/12) are allowed up to 6 lines per claim. Direct entry, claim batch or electronic submitters are allowed 50 lines per claim. Use additional claim forms if the services exceed the lines allowed. Enter the statement: “Additional services” in field 19 when billing on a hardcopy CMS-1500 claim form (version 02/12) or in the Comments section when billing electronically. Total each claim separately.



If the agency pays a claim with one or more automated/nonautomated lab tests, providers must bill any additional automated/nonautomated lab tests for the same date of service as an adjusted claim. Refer to Key Step 6 of the “Submit Fee for Service Claims to Medical Assistance” in the ProviderOne Billing and Resource Guide which addresses adjusting paid claims. Currently, providers may adjust claims electronically in ProviderOne (preferred) or send in a paper claim adjustment. Make sure the claim is adjusted with the paid automated/nonautomated lab tests using the comment "additional services."

Clinical laboratory codes Some clinical laboratory codes have both a professional component and a technical component. If performing only the technical component, bill with modifier TC. If performing only the professional component bill with modifier 26. Laboratories performing both the professional and the technical components must bill the code without a modifier. See Laboratory Physician Interpretation codes with both a technical and professional component.

Coding and payment policies 

Pathology and laboratory services must be provided either by a pathologist or by technologists who are under the supervision of a physician.



The agency expects independent laboratories to bill hospitals for the technical component of anatomic pathology services furnished to hospital inpatients and outpatients. To prevent duplicate payment, the agency will not pay independent laboratories if they bill Medicaid for these services. An independent laboratory and/or hospital laboratory must bill using its NPI for any services performed in its facility.

 

Physicians must bill using their NPI for laboratory services provided by their technicians under their supervision.



The agency pays for one blood draw fee (CPT codes 36415-36416 or 36591) per day. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

The agency pays for one catheterization for collection of a urine specimen (HCPCS code P9612) per day.



Complete blood count (CPT code 85025) includes the following CPT codes: 85004, 85007, 85008, 85009, 85013, 85014, 85018, 85027, 85032, 85041, 85048, 85049, and G0306. Complete blood count (CPT code 85027) includes the following CPT codes: 85004, 85008, 85013, 85014, 85018, 85032, 85041, 85048, 85049, and G0307.



CPT codes 81001-81003 and 81015 are not allowed in combination with urinalysis procedure 81000.



CPT codes 86812-86822 are limited to a maximum of 15 tests total for human leukocyte antigens (HLA) typing per client, per lifetime. Prior authorization is required for more than 15 tests.



Do not bill with modifier 26 if the description in CPT indicates professional services only.



Payment for lab tests includes handling, packaging and mailing fee. Separate payment is not allowed.



Laboratories must obtain PA from the ordering physician, or agency-approved genetic counselor to be paid for certain genetic testing requiring PA. All genetic testing must be billed with the appropriate genetic testing modifier.



CPT code 83037 [hemoglobin glycosylated (A1C)] does not require PA when performed in a physician’s office; however, it can be billed only once every three months. Note: Laboratory claims must include an appropriate medical diagnosis code and PA if applicable. The ordering provider must give the appropriate medical diagnosis code, prior authorization number, and modifier, if applicable, to the performing laboratory at the time the tests are ordered. The agency does not pay a laboratory for procedures billed using ICD diagnosis codes Z00.00, Z01.812, or Z01.89 as a primary diagnosis. For lab services use the appropriate diagnosis for the service(s) provided.



CPT code 87999 can be used for billing the monogram Trofile test for AIDS patients when physicians are prescribing the drug Selzentry®. The agency pays By Report for CPT code 87999.



For outpatient hospital laboratory services such as therapeutic blood levels and electrocardiograms and related professional services that are denied by managed care because the services were ordered or referred by a BHO, providers must do both of the following: CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services  

Put “Referred by the BHO” in the Comments section of the claim form. Include the managed care denial with their claim when billing the agency.

Laboratory physician interpretation procedure codes The following codes are clinical laboratory procedure codes for which separate payment for interpretations by laboratory physicians may be made. The actual performance of the tests is paid for under the Physician-Related/Professional Services fee schedule. Modifier TC must not be used with these procedure codes. The total RVUs for laboratory physician interpretation codes include values for physician work, practice expense, and malpractice expense.

84181 83020 84165 84166

84182 85390 85576

81200-81479 86255 86256 86320 86325

86327 86334 86335 87164

87207 88371 88372 89060

Laboratory codes requiring modifier and PA clarification Laboratory claims must include an appropriate medical diagnosis code, modifier, and PA, if applicable. The ordering provider must give the appropriate medical diagnosis code, modifier, and PA number, if applicable, to the performing laboratory at the time the tests are ordered. The agency does not pay for laboratory procedures billed using the appropriate ICD diagnosis codes Z00.00, Z01.812, or Z01.89. For lab services, use the appropriate diagnosis for the service(s) that was provided.

Laboratory modifiers Modifier QP Modifier QP indicates documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel. The agency recognizes this modifier as informational only. This modifier is not appropriate to use for billing repeat tests or to indicate the test was not done as a panel. Modifier 90 Reference (Outside) Laboratory: When a laboratory sends a specimen to a reference (outside) laboratory, the referring laboratory may bill for the reference laboratory (pass-through billing) by adding modifier 90 to the laboratory procedure code. The reference laboratory NPI must be entered in the performing number field on the claim form.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Modifier 91 Repeat Clinical Laboratory Diagnostic Test When it is necessary to repeat the same laboratory test on the same day for the same client to obtain subsequent (multiple) test results, use modifier 91. Otherwise, the claim will be denied as a duplicate. Do not use this modifier when tests are rerun: 

To confirm initial results.



Due to testing problems with specimens or equipment.



For any reason when a normal, one-time, reportable result is all that is required.



When there are standard procedure codes available that describe the series of results (e.g., glucose tolerance test, evocative/suppression testing, etc.).

Laboratory services referred by CMHC or DBHRcontracted providers When a community mental health center (CMHC) or DBHR-contracted providers refer clients enrolled in an agency managed care plan for laboratory services, the laboratory must bill the agency directly. All of the following conditions apply: 

The laboratory service is medically necessary.



The laboratory service is directly related to the client's mental health or alcohol and substance abuse.



The laboratory service is referred by a CMHC or DBHR-contracted provider who has a core provider agreement with the agency.



The laboratory must bill with a mental health, substance abuse, or alcohol abuse diagnosis.



The screen must meet the criteria in Drug Screens.

To bill for laboratory services, laboratories must put the CMHC or DBHR-contracted referring provider National Provider Identifier (NPI) number in the “referring provider” field of the claim form. CMHC and DBHR-contracted services are excluded from the agency’s managed care contracts. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

STAT laboratory charges When the laboratory tests listed on the following page are performed on a STAT basis, the provider may bill HCPCS code S3600 (STAT laboratory request).    

Payment is limited to one STAT charge per episode (not once per test). Tests must be ordered STAT and payment is limited to only those that are needed to manage the client in a true emergency. The laboratory report must contain the name of the provider who requested the STAT. The medical record must reflect the medical necessity and urgency of the service. Note: "STAT" must be clearly indicated by the provider and must be documented in the laboratory report and the client’s record. Tests generated from the emergency room do not automatically justify a STAT order. Use HCPCS code S3600 with the procedure codes on the following page.

The STAT charge is paid only with the following tests:

Procedure Code G0306 G0307 80047 80048 80051 80069 80076 80100 80156 80162 80170 80164 80178 80184 80185 80188 80192 80194 80196 80197 80198 81000

Short Description CBC/diffwbc w/o platelet CBC without platelet Metabolic panel ionized ca Metabolic panel total ca Electrolyte panel Renal function panel Hepatic function panel Drug screen qualitate/multi Assay, carbamazepine total Assay of digoxin Assay of gentamicin Assay dipropylacetic acid Assay of lithium Assay of phenobarbital Assay of phenytoin total Assay primidone Assay of procainamide Assay of quinidine Assay of salicylate Assay of tacrolimus Assay of theophylline Urinalysis nonauto w/scope

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148

Physician-Related Services/Health Care Professional Services Procedure Code 81001 81002 81003 81005 82003 82009 82040 82055 82150 82247 82248 82310 82330 82374 82435 82550 82565 82803 82945 82947 83615 83633 83664 83735 83874 83880 84100 84132 84155 84157 84295 84302 84450 84484 84512 84520 84550 84702 84704 85004 85007 85025 85027

Short Description Urinalysis auto w/scope Urinalysis nonauto w/o scope Urinalysis auto w/o scope Urnalysis Assay of acetaminophen Test for acetone/ketones Assay of serum albumin Assay of ethanol Assay of amylase Bilirubin total Bilirubin direct Assay of calcium Assay of calcium Assay blood carbon dioxide Assay of blood chloride Assay of ck (cpk) Assay of creatinine Blood gases any combination Glucose other fluid Assay glucose blood quant Lactate (LD) (LDH) enzyme Test urine for lactose Lamellar bdy fetal lung Assay of magnesium Assay of myoglobin Assay of natriuretic peptide Assay of phosphorus Assay of serum potassium Assay of protein serum Assay of protein other Assay of serum sodium Assay of sweat sodium Transferase (AST)(SGOT) Assay of troponin quant Assay of troponin qual Assay of urea nitrogen Assay of blood/uric acid Chorionic gonadotropin test Hcg free betachain test Automated diff wbc count Bl smear w/diff wbc count Complete cbc w/auto diff wbc Complete cbc automated

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Physician-Related Services/Health Care Professional Services Procedure Code 85032 85046 85049 85378 85380 85384 85396 85610 85730 86308 86367 86403 86880 86900 86901 86920 86921 86922 86923 86971 87205 87210 87281 87327 87400 89051 86367 86923 88720 88740 88741

Short Description Manual cell count each Reticyte/hgb concentrate Automated platelet count Fibrin degrade semiquant Fibrin degradj d-dimer Fibrinogen activity Clotting assay whole blood Prothrombin time Thromboplastin time partial Heterophile antibody screen Stem cells total count Particle agglut antbdy scrn Coombs test Blood typing ABO Blood typing rh (d) Compatibility test spin Compatibility test incubate Compatibility test antiglob Compatibility test electric Rbc pretx incubatj w/enzymes Smear gram stain Smear wet mount saline/ink Pneumocystis carinii ag if Cryptococcus neoform ag eia Influenza a/b ag eia Body fluid cell count Stem cells total count Compatibility test electric Bilirubin total transcut Transcutaneous carboxyhb Transcutaneous methb

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Medicine Allergen and clinical immunology Allergen immunotherapy (WAC 182-531-0950(10)) Subcutaneous allergen immunotherapy may be medically necessary for the following conditions in children and adults:  

Allergic rhinitis, conjunctivitis, or allergic asthma History of systemic reaction to Hymenoptera

And the client:    

Has symptoms of allergic rhinitis and/or asthma after natural exposure to the allergen OR Has life-threatening allergy to insect stings AND Has a skin test and/or serologic evidence of IgE-medicated antibody to the allergen AND Must have tried/failed attempt at allergen avoidance and pharmacologic therapy, or the client has unacceptable side effects with pharmacologic therapy

And:   

The prescribing physician must be a board certified allergist AND Immunotherapy injections must be administered in a setting that permits the prompt recognition and management of adverse reactions, particularly anaphylaxis AND If clinical improvement is not apparent after 12 months of maintenance therapy, immunotherapy should be discontinued

The agency will pay for 50 units (CPT® 95165) per client, per year. Prior authorization is required for amounts greater than 50 units per client, per year. Payment for antigen/antigen preparation (CPT codes 95145-95149, 95165, and 95170) is per dose.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Service Provided Injection and antigen/antigen preparation for allergen immunotherapy

What should I bill?  One injection (CPT code 95115 or 95117); and  One antigen/antigen preparation (CPT codes 95145-95149, 95165 or 95170).  CPT codes 95145-95149 and 95170

Antigen/antigen preparation for stinging/biting insects All other antigen/antigen preparation services (e.g., dust, pollens)

 CPT code 95144 for single dose vials; or  CPT code 95165 for multiple dose vials.  CPT code 95144

Allergist prepared the extract to be injected by another physician Allergists who billed the complete services (CPT codes 95120-95134) and used treatment boards

 One antigen/antigen preparation (CPT codes 95145-95149, 95165, and 95170); and  One injection (CPT code 95115 or 95117).  Bill for the total number of doses in the vial and an injection code  Bill only the injection service

Physician injects one dose of a multiple dose vial Physician or another physician injects the remaining doses at subsequent times

For an allergist billing both an injection and either CPT code 95144 or 95165, payment is the injection fee plus the fee of CPT code 95165, regardless of whether CPT code 95144 or 95165 is billed. The allergist may bill an Evaluation and Management (E/M) procedure code for conditions not related to allergen immunotherapy.

Audiology (WAC 182-531-0375) The agency may pay for speech/audiology program services for conditions that are the result of medically recognized diseases and defects.

Who is eligible to provide audiology services? (WAC 182-531-0375) Audiologists who are appropriately licensed or registered to provide speech/audiology services within their state of residence to agency clients.

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What type of equipment must be used? Audiologists must use annually calibrated electronic equipment, according to RCW 18.35.020. 

For caloric vestibular testing (CPT code 92543), bill one unit per irrigation. If necessary, providers may bill up to four units for each ear.



For sinusoidal vertical axis rotational testing (CPT code 92546), bill 1 unit per velocity/per direction. If necessary, providers may bill up to 3 units for each direction.

Unilateral (CPT code 69930) and bilateral (CPT code 69930 with modifier 50) cochlear implantation require EPA. See Auditory system. The agency considers requests for removal or repair of previously implanted bone anchored hearing aids (BAHA) and cochlear devices for clients age 21 and older only when medically necessary. Prior authorization from the agency is required.

Audiology billing The outpatient rehabilitation benefit limits do not apply to therapy services provided and billed by audiologists. Audiologists (and physicians) must use AF modifier when billing.

Audiology coverage table Note: Due to its licensing agreement with the American Medical Association, the agency publishes only the official, CPT® code short descriptions. To view the long descriptions, refer to a current CPT book.

Audiology Procedure Code 69210

Modifier

92507* 92508* 92521

Short Description rmvl impacted cerumen spx 1/both ears Speech/hearing therapy Speech/hearing therapy Evaluation of speech fluency

92522

Evaluate speech production

92523

Speech sound lang comprehend

EPA/PA

Policy/ Comments

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Audiology Procedure Code 92524 92551 92611 92630 92633 97532*

Modifier

97533*

92540 92540 92540 92541 92541 92541 92542 92542 92542 92543 92543 92543 92544 92544 92544 92545 92545 92545 92546 92546 92546 92547 92550 92552 92553 92555 92556 92557 92558

Short Description Behavral qualit analys voice Pure tone hearing test air Motion fluoroscopy/swallow Aud rehab pre-ling hear loss Aud rehab postling hear loss Cognitive skills development

Sensory integration

26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC

EPA/PA

Policy/ Comments

One 15 minute increment equals one visit One 15 minute increment equals one visit

Basic vestibular evaluation Basic vestibular evaluation Basic vestibular evaluation Spontaneous nystagmus test Spontaneous nystagmus test Spontaneous nystagmus test Positional nystagmus test Positional nystagmus test Positional nystagmus test Caloric vestibular test Caloric vestibular test Caloric vestibular test Optokinetic nystagmus test Optokinetic nystagmus test Optokinetic nystagmus test Oscillating tracking test Oscillating tracking test Oscillating tracking test Sinusoidal rotational test Sinusoidal rotational test Sinusoidal rotational test Supplemental electrical test Tympanometry & reflex thresh Pure tone audiometry, air Audiometry, air & bone Speech threshold audiometry Speech audiometry, complete Comprehensive hearing test Evoked auditory test qual

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Audiology Procedure Code 92567 92568 92570 92579 92582 92584 92585 92585 92585 92586 92587 92587 92587 92588 92588 92588 92601 92602

Modifier

26 TC

26 TC 26 TC

92603 92604 92620 92621 92625 92626 92627

Short Description Tympanometry Acoustic reflex testing Acoustic immittance testing Visual audiometry (vra) Conditioning play audiometry Electrocochleography Auditor evoke potent, compre Auditor evoke potent, compre Auditor evoke potent, compre Auditor evoke potent, limit Evoked auditory test Evoked auditory test Evoked auditory test Evoked auditory test Evoked auditory test Evoked auditory test Cochlear implt f/up exam < 7 Reprogram cochlear implt < 7 Cochlear implt f/up exam 7 > Reprogram cochlear implt 7 > Auditory function, 60 min Auditory function, + 15 min Tinnitus assessment Eval aud rehab status Eval aud status rehab add-on

EPA/PA

Policy/ Comments

Fee schedule View the agency’s Audiology Program Fee Schedule.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Cardiovascular Catheter ablation (CPT codes 93653, 93655, 93656, 93657) The agency covers catheter ablation for adults with the following conditions and for whom drug therapy is either not tolerated or not effective:      

Supraventricular tachyarrhythmia Symptomatic atrial fibrillation Atrial flutter Wolff-Parkinson-White (WPW) syndrome Atrioventricular nodal reentrant tachycardia (AVNRT) Atrioventricular reentrant tachycardia (AVRT)

Catheter ablation for adults is not covered for other non-reentrant supraventricular tachycardias.

Heart catheterizations When a physician performs cardiac catheterization in a setting where the physician does not own the equipment (e.g., a hospital or ASC), the agency pays providers for the appropriate procedure code with modifier 26 (professional component) only. Use cardiac catheterization and angiography to report services individually. It is not appropriate to bill with modifier 51 (multiple procedures) with any of these codes. See the agency’s Physician-Related/Professional Fee Schedule for covered codes and status indicators.

Outpatient cardiac rehabilitation The agency covers outpatient cardiac rehabilitation in a hospital outpatient agency for eligible clients who:    

Are referred by a physician. Have coronary artery disease (CAD). Do not have specific contraindications to exercise training. Have:  A recent documented history of acute myocardial infarction (MI) within the preceding 12 months.  Had coronary angioplasty (coronary artery bypass grafting [CABG].  Percutaneous transluminal coronary angioplasty [PTCA]). CPT® codes and descriptions only are copyright 2015 American Medical Association

156

Physician-Related Services/Health Care Professional Services 

Stable angina.

Bill physician services with CPT code 93797 or 93798 or HCPCS G0422 or G0423 (per session) with one of the following diagnosis codes: Acute myocardial infarction Angina pectoris Aortocoronary bypass status Percutaneous transluminal coronary angioplasty status

See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals

Note: Cardiac rehabilitation does not require PA, and it is only approved for the above diagnoses.

The outpatient cardiac rehabilitation program hospital facility must have all of the following: 

A physician on the premises at all times, and each client is under a physician’s care



Cardiopulmonary emergency equipment and therapeutic life-saving equipment available for immediate use



An area set aside for the program’s exclusive use while it is in session



Personnel who are:   

Trained to conduct the program safely and effectively Qualified in both basic and advanced life-support techniques and exercise therapy for coronary disease Under the direct supervision of a physician



Non physician personnel that are employees of the hospital



Stress testing:    



To evaluate a patient’s suitability to participate in the program To evaluate chest pain To develop exercise prescriptions For pre- and postoperative evaluation of coronary artery bypass clients

Psychological testing or counseling provided if a client: 

Exhibits symptoms such as excessive fear or anxiety associated with cardiac disease OR CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Has a diagnosed mental, psychoneurotic, or personality disorder

The agency covers up to 24 sessions (usually 3 sessions a week for 4-6 weeks) of cardiac rehabilitation sessions (phase II) per event. The agency covers continued participation in cardiac rehabilitation programs beyond 24 sessions only on a case-by case basis with prior authorization. Phase II of cardiac rehabilitation is the initial outpatient cardiac rehabilitation program. The goal of phase II is to lower the risk of future heart problems.

Central nervous system assessments/tests Coverage for developmental screening for delays and surveillance and screening for autism All children: As a part of routine well child exams for clients age 9 months, 18 months, and 30 months, the agency pays for one developmental screening for primary care providers when performed by a physician, ARNP, or PA. For further information about well child exams, see the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Provider Guide. To support timely access to a formal diagnostic evaluation and referral for applied behavioral analysis (ABA) treatment or other medically necessary services, the agency pays for one autism screening for all children at age 18 months, and a second screening before 36 months, when performed by a physician, ARNP, or PA. See the agency’s Applied Behavior Analysis Program for Clients Age 20 and Younger Program Guide for additional information. *If additional units are necessary, providers must request prior authorization from the agency.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Chemotherapy Chemotherapy services (WAC 182-531-0950(11)) Bill the appropriate chemotherapy administration CPT code for each drug administered. The agency’s chemotherapy administration policy is as follows: 

Providers may bill chemotherapy administration (CPT codes 96411 or 96417) and bill one administration for each drug given. The administration and drug must be billed on the same claim.



The agency pays for only one initial drug administration code (CPT code 96409 or 96413) per encounter unless one of the following applies:

 

Protocol requires the use of two separate IV sites. The client comes back for a separately identifiable service on the same day (in this case, bill the second initial service code with modifier -59).



The agency does not pay for Evaluation and Management (E/M) CPT code 99211 on the same date of service as the following drug administration codes: 96401-96549. If billed in combination with one of these drug administration codes, the agency will deny the E/M code 99211. However, providers may bill other E/M codes on the same date of service using modifier 25 to indicate that a significant and separately identifiable E/M service was provided. If modifier 25 is not used, the agency will deny the E/M code.



Items and services not separately payable with drug administration: Some items and services are included in the payment for the drug administration service, and the agency does not pay separately for them. These services include, but are not limited to the following:

      

The use of local anesthesia IV start Access to indwelling IV (a subcutaneous catheter or port) A flush at conclusion of an infusion Standard tubing Syringes and supplies

Infusion vs. push: An intravenous or intra-arterial push is defined as:



An injection in which the health care professional who administers the substance or drug is continuously present to administer the injection and observe the patient. OR CPT® codes and descriptions only are copyright 2015 American Medical Association

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An infusion of 15 minutes or less.

Note: Drug, infusion, and injection codes must be billed on the same claim form.

Irrigation of venous access pump CPT code 96523 may be billed as a stand-alone procedure. However, if billed by the same provider/clinic on the same day as an office visit, modifier 25 must be used to report a separately identifiable medical service. If modifier 25 is not used, the agency will deny the E/M code.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Dialysis - End-Stage Renal Disease (ESRD) Inpatient visits for hemodialysis or outpatient non-ESRD dialysis services (CPT codes 90935 and 90937) Procedure Codes Billed 90935 and 90937

Instructions Bill these codes for the hemodialysis procedure with all E/M services related to the client’s renal disease on the day of the hemodialysis procedure. Bill these codes for the following clients:  

90935 90937

Clients in an inpatient setting with ESRD Clients receiving hemodialysis in an outpatient or inpatient setting who do not have ESRD

Bill using ICD diagnosis code N18.6 or the appropriate diagnosis code (N17.2–N19, E74.8) for clients requiring dialysis but who do not have ESRD. Bill using procedure code 90935 if only one evaluation is required related to the hemodialysis procedure. Bill using procedure code 90937 if a re-evaluation(s) is required during a hemodialysis procedure on the same day.

Inpatient visits for dialysis procedures other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or continuous renal replacement therapies) (CPT codes 90945 and 90947) Procedure Codes Billed 90945 and 90947

90945 90947

Instructions Bill these codes for E/M services related to the client’s renal disease on the day of the procedure that includes peritoneal dialysis, hemofiltration, or continuous renal replacement. Bill using ICD diagnosis code N18.6 or the appropriate diagnosis code (N17.2–N19, E74.8) for clients requiring dialysis but who do not have ESRD. Bill using procedure code 90945 if only one evaluation is required related to the procedure. Bill using procedure code 90947 if a re-evaluation(s) is required during a procedure on the same day.

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If a separately identifiable service is performed on the same day as a dialysis service, any of the following E/M procedures codes may be billed with modifier 25:      

99201-99205 Office or Other Outpatient Visit: New Patient 99211-99215 Office or Other Outpatient Visit: Established Patient 99221-99223 Initial Hospital Care: New or Established Patient 99238-99239 Hospital Discharge Day Management Services 99241-99245 Office or Other Outpatient Consultations: New or Established Patient 99291-99292 Critical Care Services

Endocrinology Continuous glucose monitoring The agency pays for continuous glucose monitoring (CGM) for clients age18 and younger only. The agency pays for the in-home use of professional or diagnostic CGM for a 72 hour monitoring period with Expedited Prior Authorization (EPA). See EPA #870001312 for coverage criteria. The agency pays for CGM longer than 72 hours with prior authorization. See the agency’s Home Infusion Therapy/Parenteral Nutrition Program Provider Guide for criteria.

Hydration, therapeutic, prophylactic, diagnostic injections, infusions Hydration therapy with chemotherapy Intravenous (IV) infusion of saline (CPT codes 96360-96371) is not paid separately when administered at the same time as chemotherapy infusion (CPT codes 96413- 96417). If hydration is provided as a secondary or subsequent service after a different initial service (CPT codes 96360, 96365, 96374, 96409, 96413), and it is administered through the same IV access, report with CPT code 96361 for the first hour and again for each additional hour. Note: The CPT codes 96365-96368 are for administration of therapeutic, prophylactic or diagnostic IV infusion or injection (other than hydration).

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Therapeutic or diagnostic injections/infusions (CPT codes 96360-96379) (WAC 182-531-0950) 

If no other service is performed on the same day, a subcutaneous or intramuscular injection code (CPT code 96372) may be billed in addition to an injectable drug code.



The agency does not pay separately for intravenous infusion (CPT codes 96372-96379) if they are provided in conjunction with IV infusion therapy services (CPT codes 9636096361or 96365-96368).



The agency pays for only one initial intravenous infusion code (CPT codes 96360, 96365, or 96374) per encounter unless:

 



Protocol requires the use of two separate IV sites. OR The client comes back for a separately identifiable service on the same day. In this case, bill the second initial service code with modifier 59, XE, XS, XP, or XU.

The agency does not pay for CPT code 99211 on the same date of service as drug administration. If billed in combination, the agency denies the E/M CPT code 99211. Note: Other E/M codes may be billed on the same date of service using modifier 25 to indicate that a significant and separately identifiable service was provided. If modifier 25 is not used, the agency will deny the E/M code.

Concurrent infusion The agency pays for concurrent infusion (CPT code +96368) only once per day.

Immune Globulins, Serum, or Recombinant Products Hepatitis B (CPT code 90371) Reimbursement is based on the number of 1.0 ml syringes used. Bill each 1.0 ml syringe used as 1 unit.

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Physician-Related Services/Health Care Professional Services

Immune globulins Bill the agency for immune globulins using the HCPCS procedure codes listed below. The agency does not reimburse for the CPT codes listed in the Noncovered CPT code column below. Noncovered CPT Code 90281 90283 90284 90291 90384 90385 90386 90389

Covered HCPCS Code J1460-J1560 J1566 J1562 J0850 J2790 J2790 J2792 J1670 J1568, J1569, J1572, J1561

Rabies immune globulin (RIG) (CPT codes 90375-90376) 

RIG is given based on .06 ml per pound of body weight. The dose is rounded to the nearest tenth of a milliliter (ml). Below are the recommended dosages up to 300 pounds of body weight: Pounds 0-17 18-34 35-50 51-67 68-84 85-100 101-117 118-134 135-150

  

Dose 1 ml 2 ml 3 ml 4 ml 5 ml 6 ml 7 ml 8 ml 9 ml

Pounds 151-167 168-184 185-200 201-217 218-234 235-250 251-267 268-284 285-300

Dose 10 ml 11 ml 12 ml 13 ml 14 ml 15 ml 16 ml 17 ml 18 ml

RIG is sold in either 2 ml or 10 ml vials. One dose is allowed per episode. Bill two units for each 2 ml vial used per episode.

Examples:  If a client weighs 83 pounds, three 2 ml vials would be used. The number of units billed would be three.  If a client weighs 240 pounds, both one 10 ml vial and three 2 ml vials or eight 2 ml vials could be used. The number of units billed would be eight. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Medical genetics and genetic counseling services Genetic counseling and genetic testing The agency covers genetic counseling for all fee-for-service adults and children when performed by a physician. To bill for genetic counseling, use ICD diagnosis code Z31.5 genetic counseling and the appropriate E/M code. The agency covers genetic counseling (CPT 96040) when performed by a health care professional appropriately credentialed by the Department of Health (DOH). Certain genetic testing procedure codes need PA. Physicians must obtain PA if required for certain genetic tests and must give both the PA number and the appropriate genetic testing modifier to the laboratory or when the laboratory bills so they can bill correctly. Providers must check the Physician-Related Services Fee Schedule for services that require either PA or EPA. For procedure codes that require PA, use the General Information for Authorization form, 13835 and Fax/Written Request Basic Information form, 13-756.

Prenatal genetic counseling (chapter 246-680 and 246-825 WAC) Genetic counselors who meet the requirements in chapter 246-825 WAC are eligible to enroll with the agency to provide and receive payment for providing prenatal genetic counseling services. Genetic counselors must be approved by the Department of Health (DOH) Screening and Genetics Unit and be supervised by a practicing licensed physician.

Coverage The agency covers: 

Face-to-face encounters only, including telemedicine. Telephonic and email encounters are not covered.



One initial prenatal genetic counseling encounter. This encounter must be billed in 30minute increments and cannot exceed 90 minutes.



Two follow-up prenatal genetic counseling encounters per pregnancy. The encounters must occur no later than 11 months after conception. These encounters must be billed in 30minute increments and cannot exceed 90 minutes.

Prenatal procedures other than genetic counseling, such as laboratory or diagnostic testing, must CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services be requested directly through the client’s primary care provider (PCP) or PCCM. Note: Clients enrolled in an agency-contracted managed care organization (MCO) are covered under the fee-for-service benefit. Provider must bill the agency directly for prenatal genetic counseling provided to MCO clients. Prior authorization is not required.

Fee Schedule See the agency’s Prenatal Diagnosis Genetic Counseling fee schedule.

Billing for prenatal genetic counseling Providers must follow the billing requirements listed in the agency’s ProviderOne Billing and Resource Guide. The guide explains how to complete the CMS-1500 Claim Form. Note: Prenatal genetic clinics are asked to submit billings within 120 days of the date of service to facilitate reconciliation of Department of Health’s accounts.

Enter the following information in the listed fields on the CMS-1500 claim form: In field

Enter

24B

The appropriate place-of-service code, which must be either: 11 (office), 21 (inpatient hospital), or 22 (outpatient hospital)

24J

The taxonomy for prenatal genetic counseling: 170300000X

24J

The genetic counselor’s NPI number

33a

The approved agency’s billing NPI

33b

The approved agency’s billing taxonomy code, which cannot be 170300000X

Note: CPT code 96040 must be billed using taxonomy 170300000X for both the initial visit and the two follow-up visits. When billing the agency, providers must use ICD diagnosis code Z31.5 (genetic counseling) to receive payment for prenatal genetic counseling services. CPT code 96040 is a time-based code and each visit is limited to no more than 3 x 96040 (i.e., no more than 90 minutes per session). CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Applying to the agency to become a genetic counseling provider 

To apply to provide services, a genetic counselor must:  Complete a Core Provider Agreement (CPA) with the agency. A blank agency Core Provider Agreement may be obtained from the agency.  Send all the following to the DOH Screening and Genetics Unit at the address listed below:    

The completed CPA A DOH ABMG/ABGC certification or a letter verifying the genetic counselor's eligibility to sit for the upcoming examination Each qualified genetic counselor’s National Provider Identification (NPI) number A photocopy of the supervising physician's license Send to: Debra Lochner Doyle, MS, LCGC Department of Health, Screening and Genetics Unit 20425 72nd Ave. S. Suite 310, Kent, WA 98032 253-395-6742 Email: [email protected] DOH Website: Genetic Services Regional: Washington’s Genetic Clinics



The DOH Screening and Genetics Unit staff will send copies of the approved forms to the agency. This will serve as a written request to the agency to authorize the facility and provider to bill for genetic counseling.

After receiving the approved forms from DOH, the agency will enroll the provider as an approved genetic counseling provider. After being enrolled as a genetic counseling provider, services provided in accordance with agency policies for clients under WAC 182-502-0150 may be billed to the agency. Note: DOH-approved genetic counselors provide counseling for pregnant women (fee for service and healthy option clients) up to the end of the month containing the 60th day after the pregnancy ends. This service does not require authorization. To locate the nearest DOH-approved genetic counselor call DOH at (253) 395-6742.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Miscellaneous After-hours After-hours office codes are payable in addition to other services only when the provider’s office is not regularly open during the time the service is provided. An after-hours procedure billed for a client treated in a 24-hour facility (e.g., emergency room) is payable only in situations where a provider who is not already on-call is called to the facility to treat a client. These codes are not payable when billed by emergency room physicians, anesthesiologists/anesthetists, radiologists, laboratory clinical staff, or other providers who are scheduled to be on call at the time of service. The client’s file must document the medical necessity and urgency of the service. Only one code for after-hours services will be paid per patient, per day, and a second day may not be billed for a single episode of care that carries over from one calendar day. For example: If a clinic closes at 5pm and takes a break for dinner, and then opens back up from 6 pm-10 pm, these services are not eligible for after-hours service codes. Note: This policy does not include radiologists, pathologists, emergency room physicians, or anesthesiologists. The agency does not pay these providers for after-hour service codes.

Neurology and neuromuscular procedures Needle electromyography (EMGs) The agency has adopted Medicare-established limits for billing needle EMGs (CPT codes 95860 – 95870) as follows: CPT Code 95860 95861 95863 95864 95865 95866

95869

Short Description Muscle test one limb Muscle test 2 limbs Muscle test 3 limbs Muscle test 4 limbs Muscle test larynx Muscle test hemidiaphragm

Limits Extremity muscles innervated by three nerves or four spinal levels must be evaluated with a minimum of five muscles studied. Limited to one unit per day Limited to one unit per day Limited to one unit per day For this to pay with extremity codes 95860-95864, test must be for T3-T11 areas only; T1 or T2 alone are not separately payable.

Muscle test thor paraspinal

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Physician-Related Services/Health Care Professional Services CPT Code

Short Description

95870

Muscle test nonparaspinal

95885 95886 95887

Musc tst done w/nerv tst lim Musc test done w/n test comp Musc tst done w/n tst nonext

Limits Limited to one unit per extremity, and one unit for cervical or lumbar paraspinal muscle, regardless of number of levels tested (maximum of 5 units). Not payable with extremity codes (CPT codes 95860-95864). 3 units 3 units 1 unit

Nerve conduction study (NCS) CPT Code 95907 95908 95909 95910 95911 95912 95913

Short Description Motor&/sens 1-2 nrv cndj tst Motor&/sens 3-4 nrv cndj tst Motor&/sens 5-6 nrv cndj tst Motor&/sens 7-8 nrv cndj tst Motor&sens 9-10 nrv cndj tst Motor&/sens 11-12 nrv cndj tst Motor&/sens 13 or more nrv cndj tst

Limits 1-2 studies 3-4 studies 5-6 studies 7-8 studies 9-10 studies 11-12 studies 13 or more

Sleep medicine testing (sleep apnea) (WAC 182-531-1500) Sleep studies include polysomnography (PSG), unattended home sleep test (HST), and multiple sleep latency testing (MSLT). The agency covers attended, full-channel, PSG, MSLT, and HSTs when: 

Ordered by the client's physician.



Performed in an agency-designated center of excellence (COE) that is an independent diagnostic testing facility, sleep laboratory, or outpatient hospital.



Results are used to:  

Establish a diagnosis of narcolepsy or sleep apnea. Evaluate a client's response to therapy, such as continuous positive airway pressure (CPAP).

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Physician-Related Services/Health Care Professional Services

Provider requirements To be paid for providing sleep studies to eligible clients, the facility must: 

Be a sleep study COE. See Becoming an agency-approved sleep center.



Be currently accredited by the American Academy of Sleep Medicine (AASM) and continuously meet the accreditation standards of AASM.



Have at least one physician on staff who is board certified in sleep medicine.



Have at least one registered polysomnographic technologist (RPSGT) in the sleep lab when studies are being performed.

Coverage for clients age 18 and older For clients age 18 and older, the agency covers: 

An unattended home sleep test (HST) as follows: 

Using one of the following HST devices:  Type II home sleep monitoring device  Type III home sleep monitoring device  Type IV home sleep monitoring device that measures at least three channels





To confirm obstructive sleep apnea (OSA) in an individual with signs or symptoms consistent with OSA (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.).

Full-night, in-laboratory PSG for either of the following: 

Confirmation of obstructive sleep apnea (OSA) in an individual with signs or symptoms consistent with OSA (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.)



Titration of positive airway pressure therapy when initial PSG confirms the diagnosis of OSA, and positive airway pressure is ordered

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Split-night, in-laboratory PSG in which the initial diagnostic portion of the PSG is followed by positive airway pressure titration when the PSG meets either of the following criteria: 

The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to fifteen events per hour.



The AHI or RDI is greater than or equal to five and less than or equal to fourteen events per hour with documentation of either of the following: 

Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia



Hypertension, ischemic heart disease, or history of stroke

Coverage for clients age 17 and younger For clients age 17 and younger, the agency considers any of the following indications as medically necessary criteria for a sleep study (this is not an exhaustive list): 

OSA suspected based on clinical assessment



Obesity, Trisomy 21, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidosis (MPS), prior to adenotonsillectomy in a child



Residual symptoms of OSA following mild preoperative OSA



Residual symptoms of OSA in a child with preoperative evidence of moderate to severe OSA, obesity, craniofacial anomalies that obstruct the upper airway, or neurologic disorder following adenotonsillectomy



Titration of positive airway pressure in a child with OSA



Suspected congenital central alveolar hypoventilation syndrome or sleep-related hypoventilation due to neuromuscular disorder or chest wall deformities



Primary apnea of infancy



Evidence of a sleep-related breathing disorder in an infant who has experienced an apparent life threatening event



Child being considered for adenotonsillectomy to treat OSA

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Physician-Related Services/Health Care Professional Services 

Clinical suspicion of an accompanying sleep-related breathing disorder in a child with chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality

For clients age 17 and younger with the conditions listed above, the agency covers the following:  

Full-night, in-laboratory PSG Split-night, in-laboratory PSG

Noncovered The agency does not cover sleep studies: 

When documentation for a repeat study does not indicate medical necessity (e.g., no new clinical documentation indicating the need for a repeat study).



For the following indications, except when an underlying physiology exists (e.g., loud snoring, awakening with gasping or choking, excessive daytime sleepiness, observed cessation of breathing during sleep, etc.):  

Chronic insomnia Snoring

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Billing Agency-approved sleep centers must: 

Refer to the Physician-Related Professional Services Fee Schedule.



Enter the approved agency sleep center’s NPI where the sleep study/polysomnogram or multiple sleep latency testing was performed. Refer to Centers of Excellence for appropriate location of agency-approved sleep center. Complete claims as follows:   



For claims billed using a paper CMS-1500 form (version 02/12), enter the COE NPI in box 32. For claims billed Direct Data Entry (DDE) through the Provider Portal, click the “Other Claim Info” tab and open the Service Facility Expander under Claim Information. Enter the COE NPI in the Provider NPI Box. For claims billed using an electronic 837P claim form, enter the COE NPI in Loop 2310C, data element NM109.

Limits sleep studies to ruling out obstructive sleep apnea or narcolepsy.

See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

PLEASE NOTE: NOT FOLLOWING THESE INSTRUCTIONS MAY RESULT IN DENIAL OF YOUR CLAIM.

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Physician-Related Services/Health Care Professional Services

Sleep center physician consultations and referral for cognitive behavioral therapy (CBT) The agency requires a sleep consultation with a physician who is Board Certified in Sleep Medicine at an agency-approved sleep center for any eligible client receiving more than six months of continuous nightly use of any of the following insomnia drugs:    

Generic Zolpidem, Ambien®, Ambien CR® Sonata® Lunesta® Rozerem®

Continuous nightly use of the above insomnia drugs may be necessary for some clients, but it may not be appropriate for others. The agency covers the following drugs without prior authorization within the following limits: Drug

Limitations

Rozerem®

30 tablets/30 days for maximum of 90 days of continuous use

Generic Zolpidem, Ambien®, Ambien CR®, Sonata®, and Lunesta®

30 tablets/30 days for first fill, then 10 tablets/30 days

The agency will send a letter to the prescribing provider and the client when a sleep consultation is required, and a referral for cognitive behavioral therapy (CBT) may be recommended.

Opthalmology – vision care services (WAC 182-531-1000)

Eye examinations and refraction services The agency covers, without prior authorization (PA), eye examinations and refraction and fitting services with the following limitations: 

Once every 24 months for asymptomatic clients age 21 or older



Once every 12 months for asymptomatic clients age 20 or younger



Once every 12 months, regardless of age, for asymptomatic clients of the Developmental Disabilities Administration (DDA) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Coverage for additional examinations and refraction services The agency covers additional examinations and refraction services outside the limitation described in eye examinations and refraction services when: 

The provider is diagnosing or treating the client for a medical condition that has symptoms of vision problems or disease.



The client is on medication that affects vision. OR



The service is necessary due to lost or broken eyeglasses/contacts. In this case: 

No type of authorization is required for clients age 20 or younger or for clients of the Developmental Disabilities Administration (DDA), regardless of age.



Providers must follow the agency’s expedited prior authorization (EPA) process to receive payment for clients age 21 or older. See EPA #870000610 in Expedited Criteria Coding List. Providers must also document the following in the client's file:  

The eyeglasses or contacts are lost or broken The last examination was at least 18 months ago

Visual field exams The agency covers visual field exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries. Providers must document all of the following in the client's record:   

The extent of the testing Why the testing was reasonable and necessary for the client The medical basis for the frequency of testing

Vision therapy The agency covers orthoptics and vision therapy which involves a range of treatment modalities including:

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Physician-Related Services/Health Care Professional Services     

Lenses. Prisms. Filters. Occlusion or patching. Orthoptic/pleoptic training which is used for eye movement and fixation training.

Note: The agency requires PA for eye exercises/vision training/orthoptics/pleoptics. The agency requires expedited prior authorization (EPA) for orthoptics/pleoptic training (CPT code 97110, 97112, or 97530) when there is a secondary diagnosis of traumatic brain injury (TBI). See EPA #870001371, #870001372, and #870001373.

Ocular prosthetics The agency covers ocular prosthetics when provided by any of the following:   

An ophthalmologist An ocularist An optometrist who specializes in prosthetics

See the agency’s Prosthetic and Orthotic Devices Provider Guide for more information on coverage for ocular prosthetics.

Eye surgery Cataract surgery The agency covers cataract surgery, without PA, when the following clinical criteria are met: 

Correctable visual acuity in the affected eye is at 20/50 or worse, as measured on the Snellen test chart OR



One or more of the following conditions exist:       

Dislocated or subluxated lens Intraocular foreign body Ocular trauma Phacogenic glaucoma Phacogenic uveitis Phacoanaphylactic endopthalmitis Increased ocular pressure in a person who is blind and is experiencing ocular pain CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

The agency does not cover the following procedure codes: Procedure Code C1840 C9732

Short Description Telescopic intraocular lens Insert ocular telescope pros

Policy/ Comments Not Covered Not Covered

Strabismus surgery The agency covers strabismus surgery as follows: Clients Age 17 or younger Age 18 or older

Policy The provider must clearly document the need in the client's record. The agency does not require authorization. Covered when the clinical criteria are met. To receive payment, providers must follow the expedited prior authorization (EPA) process. The clinical criteria are:  The client has double vision; and  The surgery is not being performed for cosmetic reasons. To receive payment for clients age 18 or older, providers must use the agency’s EPA process.

Blepharoplasty or blepharoptosis surgery The agency covers blepharoplasty or blepharoptosis surgery when all of the clinical criteria are met. To receive payment, providers must follow the agency’s EPA process. The following clinical criteria must be met:  

The client's excess upper eyelid skin is blocking the superior visual field. The blocked vision is within 10 degrees of central fixation using a central visual field test.

Implantable miniature telescope The implantable miniature telescope, CPT code 66999, is used in clients with untreated, end stage, age related macular degeneration. It is a visual aid for clients with low vision, and like the other adult low vision aids, is considered vision hardware. Like all vision hardware, this is not included in the clients’ benefit package for clients age 21 and older.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Vision coverage table Due to its licensing agreement with the American Medical Association, the agency publishes only the official, CPT procedure code short descriptions. To view the long description, refer to a current CPT book.

Procedure Code Modifier Contact Lens Services

Short Description

92071

Contact lens fitting for tx

92072

Fit contact lens for managmnt

Spectacle Fitting fees, monofocal 92340 Fit spectacles monofocal 92352 Fit aphakia spectcl monofocl Spectacle Fitting fees, bifocal 92341 Fit spectacles bifocal

PA?

Policy/ Comments Ages 21-99 2 fittings every 24 months. Ages 0-20 2 fittings every 12 months. Ages 21-99 2 fittings every 24 months. Ages 0-20 2 fittings every 12 months limited to the appropriate diagnosis code. See the agency’s Program Policy Approved Diagnosis Codes for PhysicianRelated Services/Health Care Professionals.

Online Vision Care Fee Schedule

Online Vision Care Fee Schedule

No

Online Vision Care Fee Schedule

No

Online Vision Care Fee Schedule

No

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Maximum Allowable Fee

Physician-Related Services/Health Care Professional Services

Procedure Short Code Modifier Description Spectacle Fitting fees, multifocal 92342 Fit spectacles multifocal 92353 Fit aphakia spectcl multifoc

PA?

Policy/ Comments

Maximum Allowable Fee Online Vision Care Fee Schedule

No No

Note: Fitting fees are not currently covered by Medicare and may be billed directly to the agency without attaching a Medicare denial.

Procedure Code Other 92354

Modifier

Short Description

PA?

Fit spectacles single system 92355 Fit spectacles compound lens 92370 Repair & adjust spectacles 92371 Repair & adjust spectacles 92499 Eye service or procedure General Ophthalmological Services 92002 Eye exam new patient 92004 Eye exam new patient 92012 Eye exam establish patient 92014

Eye exam&tx estab pt 1/>vst

Policy/ Comments

Maximum Allowable Fee

Yes Yes No No

Applies only to clients age 20 and younger. Applies only to clients age 20 and younger.

Online Vision Care Fee Schedule

No

No No No

Online Vision Care Fee Schedule*

No

Special Ophthalmological Services 92015 Determine refractive state 92018 New eye exam & treatment 92019 Eye exam & treatment 92020 Special eye evaluation 92025 Corneal topography

No No No No Yes

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Online Vision Care Fee Schedule

Physician-Related Services/Health Care Professional Services

Procedure Code 92025 92025 92060 92060 92060 92065 92065 92065 92081 92081 92081 92082 92082 92082 92083 92083 92083 92100 92133 92133 92133 92134

Short Modifier Description TC Corneal topography 26 Corneal topography Special eye evaluation TC Special eye evaluation 26 Special eye evaluation Orthoptic/pleoptic training TC Orthoptic/pleoptic training 26 Orthoptic/pleoptic training Visual field examination(s) TC Visual field examination(s) 26 Visual field examination(s) Visual field examination(s) TC Visual field examination(s) 26 Visual field examination(s) Visual field examination(s) TC Visual field examination(s) 26 Visual field examination(s) Serial tonometry exam(s) Cmptr ophth img optic nerve Cmptr ophth img TC optic nerve Cmptr ophth img 26 optic nerve Cptr ophth dx img post segmt

PA? Yes Yes No

Policy/ Comments

No No Yes Yes Yes No No No No

No No No No

No No No No

Limited to 1 per calendar year

No No

Limited to 2 times per calendar year.

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Maximum Allowable Fee

Physician-Related Services/Health Care Professional Services

Procedure Code

Modifier

92135

TC

92135

26

92136 92136

TC

92136

26

92140 Ophthalmoscopy 92225 92226 92230 92235

92235 92240 92240 92240 92250 92250 92250

92260

PA?

Cptr ophth dx img post segmt

92134

92235

Short Description

TC 26

TC 26

TC 26

No

Ophth dx imaging post seg Ophth dx imaging post seg Ophthalmic biometry Ophthalmic biometry Ophthalmic biometry Glaucoma provocative tests

Policy/ Comments EPA required. Limited to 12 per calendar year. EPA#870000051

Maximum Allowable Fee

Online Vision Care Fee Schedule

No No No No No No

Special eye exam initial Special eye exam subsequent Eye exam with photos Eye exam with photos Eye exam with photos Eye exam with photos Icg angiography Icg angiography Icg angiography Eye exam with photos Eye exam with photos Eye exam with photos

No No No No No No No No No No No

No No

Ophthalmoscopy/

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Online Vision Care Fee Schedule

Physician-Related Services/Health Care Professional Services

Procedure Code V2630 V2631 V2632

Short Modifier Description Dynamometry Anter chamber intraocul lens Iris support intraoclr lens Post chmbr intraocular lens

PA?

26

92284 92284 92284 92285 92285

TC 26

TC

Maximum Allowable Fee

Online Vision Care Fee Schedule

Other Specialized Services 92265 Eye muscle evaluation 92265 TC Eye muscle evaluation 92265 26 Eye muscle evaluation 92270 Electrooculography 92270 TC Electrooculography 92270 26 Electrooculography 92275 Electroretinography 92275 TC Electroretinography 92275 26 Electroretinography 92283 Color vision examination 92283 TC Color vision examination 92283

Policy/ Comments

Color vision examination Dark adaptation eye exam Dark adaptation eye exam Dark adaptation eye exam Eye photography Eye photography

No No No No No No No No No No No

No No No No No No

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Online Vision Care Fee Schedule

Physician-Related Services/Health Care Professional Services

Procedure Code 92285 92286

Short Modifier Description 26 Eye photography Internal eye photography 92286 TC Internal eye photography 92286 26 Internal eye photography 92287 Internal eye photography Contact Lens Services 92310 Contact lens fitting 92311 Contact lens fitting 92312 Contact lens fitting 92313 Contact lens fitting

PA? No

Policy/ Comments

Maximum Allowable Fee

No No No No No No No No

Online Vision Care Fee Schedule

Ocular Prosthesis

See the agency’s Outpatient Hospital Provider Guide and Outpatient Prospective Payment System (OPPS) fee schedule for more information on coverage for ocular prosthetics. Contact Lens Services

92314 92315 92316 92317

Prescription of contact lens Prescription of contact lens Prescription of contact lens Prescription of contact lens

No No No No

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Online Vision Care Fee Schedule

Physician-Related Services/Health Care Professional Services

Manipulative therapy (CPT codes 98925-98929) (WAC 182-531-1050)

The agency covers: 

Ten (10) manipulative therapy treatments per client, per calendar year.



Manipulative therapy services only when provided by either an osteopathic physician licensed under chapter 18.71 RCW or a naturopathic physician licensed under chapter 18.36A RCW.



Manipulative therapy services by body regions. Body regions are defined as:     

    

abdomen and viscera cervical head lower extremities lumbar

pelvic rib cage sacral thoracic upper extremities



One manipulative therapy procedure code in the range 98925-98929 per client, per day. Bill using the CPT code that describes the number of body regions involved. For example, if three body regions are manipulated, bill one unit of CPT code 98926.



An E/M service (billed with modifier 25) in addition to the manipulative therapy service, under one of the following circumstances: 

When a provider diagnoses the condition requiring manipulative therapy and provides the therapy during the same visit



When the existing condition fails to respond to manipulative therapy or significantly changes, requiring E/M services beyond those considered included in the manipulation codes



When the provider treats the client for a condition unrelated to the manipulative therapy during the same encounter

Justification for the E/M and manipulative therapy services must be documented and kept in the client’s record for review. Note: The agency does not cover physical therapy services performed by osteopathic physicians or naturopathic physicians unless they are also physiatrists.

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Other services and procedures Hyperbaric oxygen therapy (CPT code 99183 and HCPCS G0277) Hyperbaric oxygen therapy may be considered medically necessary for treatment of the following conditions in the inpatient or outpatient hospital setting:       

    

Decompression sickness Acute carbon monoxide poisoning Acute cyanide poisoning Acute gas or air embolism Gas gangrene (clostridial myositis and myonecrosis) Progressive necrotizing soft tissue infections Acute traumatic ischemia secondary to crush injuries  For prevention of loss of function or for limb salvage  Used in combination with standard medical and surgical management Late radiation tissue injury Prevention of osteoradionecrosis following tooth extraction in a previously radiated field Refractory osteomyelitis  Unresponsive to standard medical and surgical management Compromised flaps and skin grafts  For prevention of loss of function or for limb salvage Non-healing diabetic wounds of the lower extremities  Patient has type 1 or type 2 diabetes and has a lower extremity wound that is due to diabetes  Patient has a wound classified as Wagner grade 3 or higher  Patient has failed an adequate course of standard wound therapy

The following are considered not medically necessary:       

Thermal burns Acute and chronic sensorineural hearing loss Cluster and migraine headaches Multiple sclerosis Cerebral palsy Traumatic and chronic brain injury Arterial, venous or pressure ulcers Procedure Code 99183 G0277

Short Description Hyperbaric oxygen therapy Hyperbaric oxygen

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Physician-Related Services/Health Care Professional Services Hyperbaric oxygen therapy requires EPA. See Expedited Prior Authorization Criteria Coding List, EPA #870000425. If the client does not meet the EPA criteria, prior authorization (PA) is required (see Prior Authorization). When requesting PA, provide the number of sessions being requested and the amount of time requested per session. For example: If the client is receiving a 90-minute session of hyperbaric oxygen therapy, the provider would request 1 unit of 99183 and 3 units of G0277.

Testosterone Testing (CPT 84402 and 84403) The agency covers testosterone testing for males age 19 and older. These tests require expedited prior authorization. See EPA #870001368 for coverage criteria. If the EPA criteria are not met, prior authorization is required.

Transcient Elastography The agency pays for a transient elastography such as a FibroScan® only for determining if qualifying criteria measures are met for immune modulators and anti-viral medication treatment of chronic Hepatitis C virus (HCV) infection. Transcient elastography requires EPA. See Expedited Prior Authorization Criteria Coding List, EPA #870001350.

Psychiatry Clozaril - case management 

Physicians, psychiatrists, and ARNPs must bill for Clozaril case management using the applicable E&M code for drug monitoring.



For Pharmacist billing, see the agency’s Prescription Drug Program Provider Guide.



Put “Clozaril Case Management” in the claim notes field on the claim.



The agency reimburses providers for one unit of Clozaril case management per week. 

The agency reimburses providers for Clozaril case management when billed with the appropriate ICD diagnosis codes. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.



Routine venipuncture (CPT code 36415) and a blood count (CBC) may be billed in combination when providing Clozaril case management. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

The agency does not pay for Clozaril case management when billed on the same day as any other psychiatric-related procedures.

For additional information, see the agency’s Mental Health Provider Guide.

Pulmonary Ventilator management Evaluation and Management (E/M) services are not allowed in combination with CPT codes 94002-94004, 94660, and 94662 for ventilator management on the same day, by the same provider/clinic. However, E/M services may be billed for on the same date of service using modifier 25 to indicate that a significant and separately identifiable service was provided. If modifier 25 is not used, the agency will deny the E/M code.

Special dermatological services Ultraviolet phototherapy The agency does not cover ultraviolet phototherapy (CPT code 96910) when billed with ICD diagnosis code L80 (vitiligo). The agency considers this a cosmetic procedure.

Special services Group clinical visits for clients with diabetes or asthma Overview of the program The intent of the Diabetes and Asthma Group Clinical Visits program is to provide clinical services and educational counseling to agency clients who have been diagnosed with diabetes or asthma. These visits are limited to groups of two or more clients and are payable only to physicians or advanced registered nurse practitioners (ARNPs). However, participation from other professional staff, including physician assistants, physical therapists, nurses, and nutritionists, is encouraged.

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Program requirements 

Prior to a group clinical visit, the provider must perform an assessment of individual client medical information and document the proposed treatment plan for each client.



The group clinical visit must be led by a physician or ARNP, but may include other staff as well.



The group clinical visit must last at least one hour and include: 

A group discussion on clinical issues to promote long-term disease control and self-management. This discussion should include at least one of the following topics:   

 

A question and answer period The collection of prevention-based care data needed to monitor chronic illness (e.g., weight and blood pressure) Short (approximately 5-10 minutes per client) one-on-one visits to gather needed data and establish an individual management plan with the client

 

Prevention of exacerbation or complications Proper use of medications and other therapeutic techniques (spacers, peak flow meter use; glucose measurement, foot care, eye exams, etc.) Living with a chronic illness

The following must be documented in the medical record:    

Individual management plan, including self-management capacity Data collected, including physical exam and lab findings Patient participation Beginning and ending time of the visit

Billing and reimbursement Providers must use the following CPT code when billing for diabetes or asthma group counseling visits, subject to the limitations in the table below. Providers must bill visits in increments of one-hour units (one hour = one unit). Multiple units may be billed on the same day. CPT Code 99078

Restricted to Diagnoses Diabetes and asthma. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

Visit Limitations Limited to four (4) one-hour units per calendar year, per client, per condition

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Physician-Related Services/Health Care Professional Services Note: The agency pays only for the time that a client spends in the group clinical visit.

Other limitations The agency does not reimburse a diabetes or asthma group clinical visit in conjunction with an office visit or other outpatient evaluation and management (E/M) codes for the same client, same provider, and same condition on the same day. A diabetes group clinical visit may be billed on the same day as a Department of Health (DOH) approved diabetes education core module as long as the times documented in the medical record indicate two separate sessions.

Therapies (physical, occupational, and speech therapy) Physicians, Podiatrists, Advanced Registered Nurse Practitioners (ARNP), Physician Assistants Certified (PA-C), and Wound Care Center Specialty Physicians - Billing The outpatient rehabilitation benefit limits do not apply to therapy services provided and billed by physicians, podiatrists, ARNPs, PA-Cs, and wound care center specialty physicians.

Modifier required when billing Physicians, podiatrists, ARNPs, and PA-Cs, and wound care center specialty physicians must use the following modifier when billing for PT/OT/ST services: Modality PT/OT/ST

Modifiers AF

Note: For additional information, see the agency’s Outpatient Rehabilitation Provider Guide.

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Vaccines/Toxoids (Immunizations) See Noncovered physician-related and health care professional services for vaccines that the agency does not cover. Routine vaccines are administered according to the Centers for Disease Control (CDC) advisory committee on immunization practices (ACIP) immunization schedule for adults and children in the United States.

Clients age 19 and older This section applies to clients age 19 and older. Refer to the Injectable Drugs fee schedule for a listing of covered vaccines for clients age 19 and older. Codes with a fee are paid according to the Injectable Drugs fee schedule. Note: DOH supplies free vaccines for children 0-18 years only. For clients 18 years of age and younger, see the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Provider Guide. 

Bill the agency for the cost of the vaccine by reporting the procedure code for the vaccine given.



Bill for the administration of the vaccine using CPT codes 90471 (one vaccine) and 90472 (each additional vaccine). Reimbursement is limited to one unit of 90471 and one unit of 90472 (maximum of two vaccines).



Bill for administration of nasal vaccine using CPT code 90473 (one vaccine) and 90474 (each additional vaccine). Reimbursement is limited to one unit of 90473 and one unit of 90474 (maximum of two vaccines).



Providers are reimbursed for the vaccine using the agency’s maximum allowable fee schedule.



Providers must bill 90471 and 90472 on the same claim as the procedure code for the vaccine.

If an immunization is the only service provided, bill only for the administration of the vaccine and the vaccine itself (if appropriate). Do not bill an E/M code unless a significant and separately identifiable condition exists and is reflected by the diagnosis. In this case, bill the E/M code with modifier 25. If the E/M code is billed without modifier 25 on the same date of service as a vaccine administration, the agency will deny the E/M code. Exception: The E/M code 99211 cannot be billed with a vaccine or the vaccine administration code. Note: Meningococcal vaccines (CPT codes 90733 and 90734) require EPA. See EPA #870000421. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Code Q2034 Q2035 Q2036 Q2037 Q2038 Q2039

Short Description Agriflu vaccine Afluria vacc, 3 yrs & >, im Flulaval vacc, 3 yrs & >, im Fluvirin vacc, 3 yrs & >, im Fluzone vacc, 3 yrs & >, im NOS flu vacc, 3 yrs & >, im

Comments Clients age 19 and older only Clients age 19 and older only Clients age 19 and older only Clients age 19 and older only Clients age 19 and older only Clients age 19 and older only

Note: See the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Provider Guidefor clients age 18 and younger.

Herpes Zoster (Shingles) vaccine (CPT code 90471, 90736) The agency pays for the administration of Zostavax®, the shingles vaccine as follows: 

A single dose of zoster (shingles) vaccine for adults 60 years old or older, whether or not the patient reported a prior episode of occurrence 

Zostavax® is administered subcutaneously as a single 0.65-mL dose subcutaneously in the deltoid region of the upper arm; a booster dose is not covered for this vaccine



History of varicella (chickenpox) or serologic testing for varicella immunity is not required before routine administration of zoster vaccine



If a person reports a negative history of varicella, they can still receive the Zostavax® vaccine



Use CPT code 90736 when billing for the Zostavax® vaccine



Use CPT code 90471 when billing for the administration of the Zostavax® vaccine



Clients enrolled in TAKE CHARGE or Family Planning Only are not eligible for this service

Who should not be immunized with Zostavax®: 

People who are allergic to neomycin, or any component of the vaccine



Zostavax® is a live vaccine and should not be given to individuals who have a weakened immune system caused by treatments that they are taking such as CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services radiation, a class of drugs called corticosteroids, or due to conditions such as AIDS, cancer of the lymph, bone or blood

Human papillomavirus (HPV) vaccine The agency pays for the administration of GARDASIL® HPV (Types 6, 11, 16, 18) Recombinant Vaccine as follows: 

For clients who are age 9 through 18, see the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Provider Guide.



For clients who are age 19 through 26: 

GARDASIL® must be prescribed and administered in a series of three shots.



When billing for only the GARDASIL® vaccine and not the administration, use either procedure code 90649 or 90650 on the claim.



Bill the agency for the administration of GARDASIL® to eligible Medicaid clients, by using either procedure code 90471 or 90472.



DO NOT use modifier SL on claims for any of the types of vaccines.

The agency uses the maximum allowable fee schedule to pay claims for vaccines. Clients enrolled in TAKE CHARGE, Family Planning Only, and the Alien Emergency Only programs are not eligible for this service.

Billing for infants not yet assigned a ProviderOne client ID Use the mother’s ProviderOne Client ID for a newborn if the infant has not yet been issued a ProviderOne Client ID. Enter indicator SCI=B in the Comments section of the claim to indicate that the mom’s ProviderOne Client ID is being used for the infant. Put the child’s name, gender, and birthdate in the client information fields. When using a mom’s ProviderOne Client ID for twins, triplets, etc., identify each infant separately (i.e., twin A, twin B), using a separate claim form for each. Note: For a mother enrolled in an agency managed care organization (MCO), the MCO is responsible for providing medical coverage for the newborn(s).

Injectable and nasal flu vaccines The agency pays for injectable (see the agency’s Injectable Drugs Fee Schedule for coverage details) and nasal flu vaccines. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Maternity Care and Delivery Elective deliveries The agency does not reimburse for early elective deliveries. An early elective delivery is defined in WAC 182-500-0030 as any nonmedically necessary induction or cesarean section before 39 weeks gestation. An early elective delivery is considered medically necessary if the mother or fetus has a diagnosis listed in the Joint Commission’s current table of Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation (WAC 182-533-0400). If the client meets the medical necessity criteria, bill using EPA #870001375. This EPA also needs to be used for clients who deliver naturally prior to 39 weeks. If the early elective delivery does not meet medical necessity criteria, the agency will pay only for the antepartum and postpartum professional services. When billing, these services must be unbundled. The agency will not pay for the delivery services. For all deliveries for a client equal to or over 39 weeks gestation, bill using EPA #870001378. This applies to both elective and natural deliveries for clients equal to or over 39 weeks gestation.

Prenatal assessments not covered The agency does not cover prenatal assessments. If a client is seen for reasons other than routine antepartum or postpartum care, providers must bill using the appropriate Evaluation and Management (E/M) procedure code with a medical diagnosis code. E/M codes billed with the appropriate ICD diagnosis codes Z33.1, Z34.00, Z34.80, or Z34.90 will be denied if listed as the principal diagnosis. Exception: Providers must bill E/M codes for antepartum care if only 1-3 antepartum visits are done. For information regarding family planning services, including long-acting reversible contraceptives (LARC), see the Family Planning Provider Guide.

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Confirmation of pregnancy If a client presents with signs or symptoms of pregnancy and the purpose of the client’s visit is to confirm the pregnancy, bill this visit using the appropriate level E/M code, if the obstetrical (OB) record is not initiated. If the OB record is initiated at this visit, then the visit is considered part of the global OB package and must not be billed separately. If some other source has confirmed the pregnancy and the provider wants to do his/her own confirmation, bill this visit using the appropriate level E/M code if the OB record is not initiated. If the OB record is initiated at this visit, the visit is considered part of the global OB package and must not be billed separately. If the purpose of the client’s visit is to confirm the pregnancy and the OB record is not initiated, bill using the diagnosis code(s) for the signs and/or symptoms the client is having [e.g. suppressed menstruation (ICD diagnosis code N92.5 or N93.8)]. Do not bill using the pregnancy diagnosis codes (e.g. Z33.1, Z34.00, Z34.80, or Z34.90) unless the OB record is initiated at this visit. If the OB record is initiated at this visit, the visit is considered part of the global package. See ultrasonography in pregnancy in this guide. The agency does not pay separately for CerviLenz. It is considered bundled into the practice expense.

Global (total) obstetrical (OB) care Global OB care (CPT codes 59400, 59510, 59610, or 59618) includes all the following:   

Routine antepartum care in any trimester Delivery Postpartum care

If the provider furnishes all of the client’s antepartum care, perform the delivery, and provide the postpartum care, the provider must bill using one of the global OB procedure codes. Use HCPCS code 0500F along with the appropriate billing code on the first prenatal visit. The agency is tracking the date a client begins receiving obstetrical care (date the OB record is initiated). Note this date by entering HCPCS code 0500F with the appropriate ICD diagnosis codes Z33.1, Z34.00, Z34.80, or Z34.90 on the claim. Note: When billing global Obstetrical Services, the place of service code must correspond with the place where the child was born (for example: 25).

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Physician-Related Services/Health Care Professional Services When more than one provider in the same clinic (same group NPI) sees the same client for global maternity care, the agency pays only one provider for the global (total) obstetrical care. Providers who are in the same clinic who do not have the same group NPI must not bill the agency the global (total) obstetrical care procedure codes. In this case, the OB services must be unbundled and the antepartum, delivery, or postpartum care must be billed separately. Note: Do not bill the agency for maternity services until all care is completed.

Unbundling obstetrical care In the situations described below, providers may not be able to bill the agency for global OB care. In these cases, it may be necessary to unbundle the OB services and bill the antepartum, delivery, and postpartum care separately, as the agency may have paid another provider for some of the client’s OB care, or a provider may have been paid by another insurance carrier for some of the client’s OB care. When a client transfers to a practice late in the pregnancy… 

If the client has had antepartum care elsewhere, the subsequent provider must not bill the global OB package. Bill the antepartum care, delivery, and postpartum care separately. The provider that had been providing the antepartum care bills for the services that he/she performed. Therefore, if the subsequent provider bills the global OB package, that provider is billing for some antepartum care that another provider has claimed. - OR –



If the client did not receive any antepartum care prior to coming to the provider’s office, bill the global OB package. In this case, the provider may actually perform all of the components of the global OB package in a short time. The agency does not require this provider to perform a specific number of antepartum visits in order to bill for the global OB package.

If a client moves to another provider (not associated with the providers practice), moves out of the area prior to delivery, or loses the pregnancy… When physician A has seen the client for part of the antepartum care and has transferred the client to physician B for care, and physician B is billing separately for the antepartum care being delivered, physician B enters “transfer of care” in the Comments field on the 837P claim, the claims notes field of the DDE, or field 19 on the CMS-1500 paper claim (version 02/12). Physician B bills only those services actually provided to these clients.

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Physician-Related Services/Health Care Professional Services If a client changes insurance during her pregnancy… Often, a client is fee-for-service at the beginning of her pregnancy and enrolled in an agency managed care organization for the remainder of her pregnancy. The agency is responsible for paying only those services provided to the client while she is on fee-for-service. The managed care organization (MCO) pays for services provided after the client is enrolled with the plan. The agency encourages early prenatal care and is actively enrolling new clients into the Healthy Options program. If a client is on fee-for-service and is enrolling in a Healthy Options plan at the beginning of her pregnancy, consider billing the first visit as a secondary confirmation of pregnancy using ICD diagnosis code N92.5 or N93.8 with the appropriate level of office visit as described under the Confirmation of Pregnancy section. When a client changes from one plan to another, bill those services that were provided while she was enrolled with the original plan to the original carrier, and those services that were provided under the new coverage to the new plan. The provider must unbundle the services and bill the antepartum, delivery, and postpartum care separately. For clients who move in and out of managed care and fee for service, use TH and CG modifiers to unbundle the codes.

Antepartum care Per CPT guidelines, the agency considers routine antepartum care for a normal, uncomplicated pregnancy to consist of:   

Monthly visits up to 28 weeks gestation. Biweekly visits to 36 weeks gestation. Weekly visits until delivery.

Antepartum care includes:      

Initial and subsequent history. Physical examination. Recording of weight and blood pressure. Recording of fetal heart tones. Routine chemical urinalysis. Maternity counseling, such as risk factor assessment and referrals.

Necessary prenatal laboratory tests may be billed in addition to antepartum care, except for the following tests (CPT codes 81000, 81001, 81002, 81003, and 81007).

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Coding for antepartum care only If it is necessary to unbundle the OB package and bill separately for antepartum care, bill as follows: 

If the client had a total of one to three antepartum visits, bill the appropriate level of E/M service with modifier TH for each visit, with the date of service the visit occurred and the appropriate diagnosis. Modifier TH: Obstetrical treatment/service, prenatal or postpartum



If the client had a total of four to six antepartum visits, bill using CPT code 59425 with a "1" in the units box. Bill the agency using the date of the last antepartum visit in the to and from fields.



If the client had a total of seven or more visits, bill using CPT code 59426 with a "1" in the units box. Bill the agency using the date of the last antepartum visit in the to and from fields.

Do not bill antepartum care only codes in addition to any other procedure codes that include antepartum care (i.e. global OB codes). When billing for antepartum care, do not bill using CPT E/M codes for the first three visits, then CPT code 59425 for visits four through six, and then CPT code 59426 for visits seven and on. These CPT codes are used to bill only the total number of times the client was seen for all antepartum care during her pregnancy, and may not be billed in combination with each other during the entire pregnancy period. For those clients who have non-maternity-related issues and diagnosis(es), the provider should use the appropriate E&M code with the modifier GB. Note: Do not bill the agency until all antepartum services are complete. Hospital care for pregnant women can be billed concurrently.

Coding for deliveries If it is necessary to unbundle the OB package and bill for the delivery only, bill the agency using one of the following CPT codes:   

59409 (vaginal delivery only) 59514 (cesarean delivery only) 59612 [vaginal delivery only, after previous cesarean delivery (VBAC)] CPT® codes and descriptions only are copyright 2015 American Medical Association

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59620 [cesarean delivery only, after attempted vaginal delivery after previous cesarean delivery (attempted VBAC)]

If a provider does not furnish antepartum care, but performs the delivery and provides postpartum care, bill the agency one of the following CPT codes:    

59410 (vaginal delivery, including postpartum care) 59515 (cesarean delivery, including postpartum care) 59614 (VBAC, including postpartum care) 59622 (attempted VBAC, including postpartum care)

Coding for postpartum care only If it is necessary to unbundle the OB package and bill for postpartum care only, bill the agency using CPT code 59430 (postpartum care only). If a provider furnishes all of the antepartum and postpartum care, but does not perform the delivery, bill the agency for the antepartum care using the antepartum care only codes, along with CPT code 59430 (postpartum care only). Do not bill CPT code 59430 (postpartum care only) in addition to any procedure codes that include postpartum care. Postpartum care includes office visits for the six week period after the delivery and includes family planning counseling and contraceptive management.

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Billing with modifiers For those clients who have either a non-maternity related issue or a high-risk medical condition, the provider should use the appropriate E/M procedure code with modifier GB. Nonsupervision, not part of global, medical diagnosis is always primary. Modifiers All of these modifiers must be used with E/M only

GB

CG

TH

UA

Nonsupervision, not part of global, high risk medical condition or condition unrelated to the pregnancy, which is always primary reason for the visit.

Supervision when client is in and out of managed care

Supervision of the client when the provider treats client for less than four visits and unbundles care

Supervision with additional visits beyond global (for high-risk pregnancy)

Do not use a supervision diagnosis code. Multiple providers for OB care Providers seeing client for medical reasons other than current pregnancy

X

X

High risk pregnancy and all prenatal OB care Client moves from managed care to/from FFS Perinatologist visit for preexisting condition and client is now pregnant (visit is outside of OB care/outside of OB bundle) Antepartum care and/or postpartum care if only 1-3 visits

X X

X

X

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Additional monitoring for high-risk conditions When providing additional monitoring for high-risk conditions in excess of the CPT guidelines for normal antepartum visits, bill using E/M codes 99211-99215 with modifier UA. The office visits may be billed in addition to the global fee only after exceeding the CPT guidelines for normal antepartum care. Providers must bill with a primary diagnosis that identifies that the high risk condition is pregnancy related. A condition that is classifiable as high-risk alone does not entitle the provider to additional payment. Per CPT guidelines, it must be medically necessary to see the client more often than what is considered routine antepartum care in order to qualify for additional payments. The additional payments are intended to cover additional costs incurred by the provider as a result of more frequent visits. For example: Client A is scheduled to see her provider for her antepartum visits on January 4, February 5, March 3, and April 7. The client attends her January and February visits, as scheduled. However, during her scheduled February visit, the provider discovers the client’s blood pressure is slightly high and wants her to come in on February 12 to be checked again. At the February 12 visit, the provider discovers her blood pressure is still slightly high and asks to see her again on February 18. The February 12 and February 18 visits are outside of her regularly scheduled antepartum visits and outside of the CPT guidelines for routine antepartum care since she is being seen more often than once per month. The February 12 and February 18 visits may be billed separately from the global antepartum visits using the appropriate E/M codes with modifier UA, and the diagnosis must represent the medical necessity for billing additional visits. A normal pregnancy diagnosis (i.e. Z33.1, Z34.00, Z34.80, or Z34.90) will be denied outside of the global antepartum care. It is not necessary to wait until all services included in the routine antepartum care are performed to bill the extra visits, as long as the extra visits are outside of the regularly scheduled visits.

Labor management Providers may bill for labor management only when another provider (outside of the first provider’s group practice) performs the delivery. If a provider performed all of the client’s antepartum care, admitted the client to the hospital during labor, delivered the baby, and performed the postpartum care, do not bill the agency for the hospital admission or for labor management. These services are included in the global OB package. If, however, a provider performed all of the client’s antepartum care and admitted the client to the hospital during labor, but another provider (outside of the first provider’s group practice) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services takes over delivery, the global OB package must be unbundled and the providers must bill separately for antepartum care, the hospital admission, and the time spent managing the client’s labor. The client must be in active labor and admitted to a hospital when the referral to the delivering provider is made. To bill for labor management in the situation described above, bill the agency for one of the hospital admission CPT codes 99221-99223 with modifier TH. In addition to the hospital admission, the agency pays providers for up to three hours of labor management using prolonged services CPT codes 99356-99357 with modifier TH. Payment for prolonged services is limited to three hours per client, per pregnancy, regardless of the number of calendar days a client is in labor, or the number of providers who provide labor management. Labor management may not be billed by the delivering provider, or by any provider within the delivering provider’s group practice. Note: 1.

The agency pays for prolonged services CPT codes for labor management only when the provider performs the hospital admission and labor management services on the same day.

2.

The hospital admission code and prolonged services code(s) must be billed on the same claim form with the same dates of services.

High-risk deliveries Delivery includes management of uncomplicated labor and vaginal delivery (with or without episiotomy, with or without forceps) or cesarean section. If a complication occurs during delivery resulting in an unusually complicated, high-risk delivery, the agency pays providers an additional add-on fee. Bill the high-risk add-on fee by adding modifier TG to the delivery code (e.g. 59400 TG or 59409 TG). Modifier TG: Complex/high level of care The ICD diagnosis code must clearly demonstrate the medical necessity for the high-risk delivery add-on (e.g. a diagnosis of fetal distress). A normal delivery diagnosis is not paid an additional high-risk add-on fee, even if the mother had a high-risk condition during the antepartum period.

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Physician-Related Services/Health Care Professional Services Bill only ONE line of service (e.g. 59400 TG) to receive payment for BOTH the delivery and the high-risk add-on. DO NOT bill the delivery code (e.g. 59400) on one line of the claim form and the high-risk add-on (e.g. 59400 TG) on a second line of the claim form. A physician who provides stand-by attendance for high-risk delivery can bill CPT code 99360 and resuscitation CPT code 99465, when appropriate. Note: The agency does not pay an assistant surgeon, RNFA, or co-surgeon for a high-risk delivery add-on. Payment is limited to one per client, per pregnancy (even in the case of multiple births).

Consultations If another provider refers a client during her pregnancy for a consultation, bill the agency using consultation CPT codes 99241-99245. If an inpatient consultation is necessary, bill using CPT codes 99251 – 99255 or for a follow-up bill using CPT codes 99231-99233. The referring physician’s name and NPI must be listed in the Referring Physician field on the claim form. If the consultation results in the decision to perform surgery (i.e. a cesarean section), the agency pays the consulting physician for the consultation as follows: 

If the consulting physician does not perform the cesarean section, bill the agency the appropriate consultation code.



If the consulting physician performs the cesarean section and does the consultation two or more days prior to the date of surgery, bill the agency the appropriate consultation code with modifier 57 (e.g. 99241-57).

The agency does not pay the consulting physician if the following applies: 

If the consulting physician performs the cesarean section and does the consultation the day before or the day of the cesarean section, the consultation is bundled within payment for the surgery. Do not bill the agency for the consultation in this situation.

Bill the agency for consultations using an appropriate ICD diagnosis code. The medical necessity (i.e. sign, symptom, or condition) must be demonstrated. The agency does not pay providers for a consultation with a normal pregnancy diagnosis code (e.g. Z33.1, Z34.00, Z34.80, or Z34.90). The agency pays consulting OB/GYN providers for an external cephalic version (CPT code 59412) and a consultation when performed on the same day.

CPT® codes and descriptions only are copyright 2015 American Medical Association

202

Physician-Related Services/Health Care Professional Services

General obstetrical payment policies and limitations 

The agency pays a multiple vaginal delivery (for twins, triplets, etc.) at 100% for the first baby. When billing for the second or third baby, bill using the delivery-only code (CPT code 59409 or 59612) for each additional baby. Payment for each additional baby will be 50% of the delivery-only code's maximum allowance. Bill each baby's delivery on a separate line. Identify on the claim form as "twin A" or "twin B," etc.



The agency pays for multiple births by cesarean delivery at 100% for the first baby. No additional payment will be made for additional babies.



Physician assistants-certified (PA-C) must bill for assisting during a C-section on their own claim form using modifier 80, 81, or 82 to the delivery-only code (e.g. 59514-80). The claim must be billed using the PA-C’s NPI.



Physician assistants (PA) must bill for an assist by adding modifier 80, 81, or 82 to the delivery-only code (e.g. 59514-80).



RNFAs assisting at C-sections may only bill using CPT code 59514 or 59620 with modifier 80.



To bill for anesthesia during delivery, see Anesthesia for Maternity .



For deliveries in a birthing center, see the agency’s Planned Home Births and Births in Birthing Centers Provider Guide.



For deliveries in a home birth setting, see the agency’s Planned Home Births and Births in Birthing Centers Provider Guide.

Note: Maternity Support Services/Infant Case Management (MSS/ICM) are services provided through the First Steps program. Services are designed to help pregnant women and their newborns gain access to medical, social, educational and other services. MSS and ICM provide a variety of services in the home or clinic throughout pregnancy and up to the infant’s first birthday. For information on MSS/ICM, see the agency’s Maternity Support Services/Infant Case Management Provider Guide.

CPT® codes and descriptions only are copyright 2015 American Medical Association

203

Physician-Related Services/Health Care Professional Services

HIV/AIDS counseling/testing (WAC 182-531-0600) See HIV/AIDS counseling/testing for coverage policy. Exceptions: The agency pays for counseling visits when billed with an E/M service on the same day when:  

The client is being seen for a medical problem and modifier 25 is billed. OR The client is being seen for an antepartum visit and modifier TH is used.

The agency does not pay for a counseling visit if the client is being seen only to confirm pregnancy and an office visit is billed, because the counseling is considered part of the office visit. The agency covers HIV testing (86701-86703) for pregnant women when billed with the following appropriate diagnosis codes: Z33.1, Z34.00, Z34.80, Z34.90 or Z36. The following tables summarize billing the agency for maternity-related services.

Global (total) obstetrical (OB) care Service Confirmation of pregnancy Global OB care

Procedure Code/Modifier 99201-99215

Short Description Office visits

59400

Obstetrical care

59510 59610 59618

Cesarean delivery Vbac delivery Attempted vbac delivery

Limitations Code the sign or symptom (e.g. suppressed menstruation) Includes all antepartum, delivery, and postpartum care; bill after all services are complete; limited to one per client, per pregnancy; additional vaginal deliveries for multiple bills must be billed with the appropriate delivery-only code.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Antepartum care only Service Antepartum care (bill only one of these codes to represent the total number of times the client was seen for antepartum care)

Procedure Code/Modifier 99201-99215 TH 59425

Short Description Offices visits, antepartum care 1-3 visits only, with OB service modifier Antepartum care only

59426

Antepartum care only

Limitations Limited to 3 units when used for routine antepartum care. Modifier TH must be billed. Limited to one unit per client, per pregnancy, per provider Limited to one unit per client, per pregnancy, per provider.

Deliveries Service Delivery only

Delivery with postpartum care

Procedure Code/Modifier 59409 59514 59612 59620 59410 59515 59614 59622

Short Description Obstetrical care Cesarean delivery only Vbac delivery only Attempted VBAC delivery only Obstetrical care Cesarean delivery Vbac care after delivery Attempted vbac after care

Limitations Must not be billed with any other codes that include deliveries; assist at c-section must be billed with deliveryonly code with modifier 80. Must not be billed with any other codes that include deliveries; must not be billed with postpartum only code; limited to one per client, per pregnancy; additional vaginal deliveries for multiple births must be billed using the appropriate delivery-only code.

Postpartum care only Service Postpartum care only

Procedure Code/Modifier 59430

Short Description Care after delivery

Limitations Must not be billed with any other codes that include postpartum care; limited to one per client, per pregnancy.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Additional monitoring for high-risk conditions Service Additional visits for antepartum care due to highrisk conditions

Procedure Code/Modifier 99211-99215 UA

Short Description Office/outpatient visit est

Limitations Must not be billed with a normal pregnancy diagnosis (Z33.1, Z34.00, Z34.80, or Z34.90); diagnosis must detail need for additional visits; must be billed with modifier UA.

Labor management Service Labor management (may only be billed when another provider takes over and delivers the infant)

Procedure Code/Modifier 99221-99223 TH +99356 TH Limited to 1 unit +99357 TH Limited to 4 units

Short Description Initial hospital care

Prolonged service inpatient

Prolonged service inpatient

Limitations Prolonged services are limited to 3 hours per client, per pregnancy; must be billed with modifier TH; must not be billed by delivering provider. Admit code with modifier TH and the prolonged services code(s) must be billed on the same claim form.

High-risk deliveries Service High-risk delivery [Not covered for assistant surgeons, cosurgeons, or RNFA]

Procedure Code/Modifier Add modifier TG to the delivery code (e.g. 59400 TG)

Short Description Complex/high level of care

Limitations Diagnosis must demonstrate medical necessity; not paid with normal delivery diagnosis; limited to one per client, per pregnancy. Bill only ONE line of service (e.g. 59400 TG) for BOTH the delivery and high-risk add-on.

CPT® codes and descriptions only are copyright 2015 American Medical Association

206

Physician-Related Services/Health Care Professional Services

Abortion services (drug induced) 

Methotrexate and misoprostol are two drugs approved by the Food and Drug Administration (FDA) for use in inducing abortions.

 

J9260 Methotrexate sodium, 50 mg S0191 Misoprostol, oral, 200 mcg



When these drugs are used for abortion services, providers must bill using the appropriate ICD diagnosis code for abortion. Other medical services (laboratory, history/physical, ultrasound, etc.) performed at the time of the drug administration must be billed on the same claim as the abortion drugs.



Rho(D) immune globulin must be billed using the appropriate HCPCS codes.



Clients enrolled in an agency managed care organization (MCO) may self-refer outside the MCO for abortions.

RU-486 Abortion Drug The agency pays for RU-486 for medically induced abortions provided through physicians’ offices using the codes in the following table. Office visits, laboratory tests, and diagnostic tests performed for the purpose of confirming pregnancy, gestational age, and successful termination must be billed on the same claim form as the abortion drugs. Bill HCPCS Code S0190 S0191

Short Description Mifepristone, oral, 200 mg Misoprostol, oral, 200 mcg

Abortion centers (nonhospital-based) must be approved by the agency to be able to bill for facility fee payments. To become an abortion center provider, fax a request to the agency’s program manager at 360-725-1966.

Abortion center contracts (facility fees) For providers who currently have an abortion center contract with the agency, facility fees are payable only for surgical abortions. Do not bill facility fee charges for drug-induced abortions not requiring surgical intervention. The agency pays the contractor facility fees for surgical abortion services once per abortion, per eligible client. Clients on the Family Planning Only program are not eligible for abortions. Refer them to their local Community Service Office to request a change in their eligibility since they are pregnant. Clients enrolled in an agency managed care organization can self-refer for abortions. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Contracted facility fee payment includes all room charges, equipment, supplies, and drugs (including anti-anxiety, antibiotics, and pain medications, but excluding Rho(D) immune globulins). Payment is limited to one special agreement facility fee per client, per abortion. The facility fee is not payable per visit, even though a particular procedure or case may take several days or visits to complete. The facility fee does not include professional services, lab charges, or ultrasound and other X-rays, which can be billed separately.

CPT® codes and descriptions only are copyright 2015 American Medical Association

208

Physician-Related Services/Health Care Professional Services

Medical Supplies and Equipment General payment policies 

The agency pays providers for certain medical supplies and equipment (MSE) dispensed from their offices when these items are considered prosthetics and are used for a client’s permanent condition (see Supplies Included in an Office Call-Bundled Supplies).



Most MSE used to treat a client’s temporary or acute condition are considered incidental to a provider’s professional services and are bundled in the office visit payment (see Supplies Included in an Office Call-Bundled Supplies). The agency pays providers separately for only those MSE listed see Supplies Included in an Office Call-Bundled Supplies.



The agency does not pay providers separately for surgical trays, as these are bundled within the appropriate surgical procedure. The fees for these procedures include the cost of the surgical trays.



Procedure codes for MSE that do not have a maximum allowable fee and cost less than $50.00 are paid at acquisition cost. A manufacturer’s invoice must be maintained in the client’s records for MSE under $50.00 and made available to the agency upon request. DO NOT send in an invoice with a claim for MSE under $50.00 unless requested by the agency.



Procedure codes for MSE that do not have a maximum allowable fee and cost $50.00 or more are paid at acquisition cost. A copy of the manufacturer’s invoice must be attached to the claim for MSE costing $50.00 or more. Note: Refer to Resources Available for information on prior authorization.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Supplies included in an office call (bundled supplies) Items with an asterisk (*) in the following list are considered prosthetics when used for a client’s permanent condition. The agency pays providers for these supplies when they are provided in the office for permanent conditions only. They are not considered prosthetics if the condition is acute or temporary. Providers must indicate “prosthetic for permanent condition” in the Comments section of the claim form. For example, if a patient has an indwelling Foley catheter for permanent incontinence and a problem develops for which the physician is required to replace the catheter, it is considered a prosthetic and is paid separately. The Foley catheter used to obtain a urine specimen, used after surgery, or used to treat an acute obstruction is not paid separately because it is treating a temporary problem. HCPCS Code 99070 A4206 A4207 A4208 A4209 A4211 A4212 A4213 A4215 A4220 A4244 A4245 A4246 A4247 A4252 A4253 A4256 A4258 A4259 A4262 A4263 A4265 A4270 A4300 A4301 A4305

Short Description Special supplies phys/qhp 1 CC sterile syringe&needle 2 CC sterile syringe&needle 3 CC sterile syringe&needle 5+ CC sterile syringe&needle Supp for self-adm injections Non coring needle or stylet 20+ CC syringe only Sterile needle Infusion pump refill kit Alcohol or peroxide, per pint Alcohol wipes per box Betadine/phisohex solution Betadine/iodine swabs/wipes Blood ketone test or strip Blood glucose/reagent strips Calibrator solution/chips Lancet device each Lancets per box Temporary tear duct plug Permanent tear duct plug Paraffin Disposable endoscope sheath Cath impl vasc access portal Implantable access syst perc Drug delivery system >=50 ML

CPT® codes and descriptions only are copyright 2015 American Medical Association

210

Physician-Related Services/Health Care Professional Services HCPCS Code A4306 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4330 A4335* A4338* A4340* A4344* A4346* A4351 A4352 A4353 A4354 A4355 A4356* A4357* A4358* A4361* A4362* A4364* A4367* A4368* A4397 A4398* A4399* A4400* A4402 A4404* A4421* A4455 A4461 A4463 A4465 A4470 A4480 A4550

Short Description Drug delivery system <=50 ml Insert tray w/o bag/cath Catheter w/o bag 2-way latex Cath w/o bag 2-way silicone Catheter w/bag 3-way Cath w/drainage 2-way latex Cath w/drainage 2-way silcne Cath w/drainage 3-way Irrigation tray Stool collection pouch Incontinence supply Indwelling catheter latex Indwelling catheter special Cath indw foley 2 way silicn Cath indw foley 3 way Straight tip urine catheter Coude tip urinary catheter Intermittent urinary cath Cath insertion tray w/bag Bladder irrigation tubing Ext ureth clmp or compr dvc Bedside drainage bag Urinary leg or abdomen bag Ostomy face plate Solid skin barrier Adhesive, liquid or equal Ostomy belt Ostomy filter Irrigation supply sleeve Ostomy irrigation bag Ostomy irrig cone/cath w brs Ostomy irrigation set Lubricant per ounce Ostomy ring each Ostomy supply misc Adhesive remover per ounce Surgicl dress hold non-reuse Surgical dress holder reuse Non-elastic extremity binder Gravlee jet washer Vabra aspirator Surgical tray

CPT® codes and descriptions only are copyright 2015 American Medical Association

211

Physician-Related Services/Health Care Professional Services HCPCS Code A4556 A4557 A4558 A4649 A5051* A5052* A5053* A5054* A5055* A5061* A5062* A5063* A5071* A5072* A5073* A5081* A5082* A5083* A5093* A5102* A5105* A5112* A5113* A5114* A5120 A5121* A5122* A5126* A5131* A6021 A6022 A6023 A6024 A6025 A6154 A6231 A6232 A6233 A6413

Short Description Electrodes, pair Lead wires, pair Conductive paste or gel Surgical supply Pouch clsd w barr attached Clsd ostomy pouch w/o barr Clsd ostomy pouch faceplate Clsd ostomy pouch w/flange Stoma cap Pouch drainable w barrier at Drnble ostomy pouch w/o barr Drain ostomy pouch w/flange Urinary pouch w/barrier Urinary pouch w/o barrier Urinary pouch on barr w/flng Continent stoma plug Continent stoma catheter Stoma absorptive cover Ostomy accessory convex inse Bedside drain btl w/wo tube Urinary suspensory Urinary leg bag Latex leg strap Foam/fabric leg strap Skin barrier, wipe or swab Solid skin barrier 6x6 Solid skin barrier 8x8 Disk/foam pad +or- adhesive Appliance cleaner Collagen dressing <=16 sq in Collagen drsg>16<=48 sq in Collagen dressing >48 sq in Collagen dsg wound filler Silicone gel sheet, each Wound pouch, each Hydrogel dsg <=16 sq in Hydrogel dsg>16<=48 sq in Hydrogel dressing >48 sq in Adhesive bandage, first-aid

CPT® codes and descriptions only are copyright 2015 American Medical Association

212

Physician-Related Services/Health Care Professional Services

Alcohol and Substance Misuse Counseling The agency covers alcohol and substance misuse counseling through screening, brief interventions, and referral to treatment (SBIRT) services when provided by, or under the supervision of, a certified physician or other certified licensed health care professional within the scope of their practice. SBIRT is a comprehensive, evidenced-based public health practice designed to identify people who are at risk for or have some level of substance use disorder which can lead to illness, injury, or other long-term morbidity or mortality. SBIRT services are provided in a wide variety of medical and community health care settings such as primary care centers, hospital emergency rooms, and trauma centers (see list of SBIRT places of service).

What is included in SBIRT? Screening. With just a few questions on a questionnaire or in an interview, practitioners can identify patients who have alcohol or other drug (substance) use problems and determine how severe those problems already are. Three of the most widely used screening tools are the Alcohol Use Disorders Identification Test (AUDIT), the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and the Drug Abuse Screening Test (DAST). Brief intervention. If screening results indicate at risk behavior, individuals receive brief interventions. The intervention educates them about their substance use, alerts them to possible consequences and motivates them to change their behavior. Referral to treatment. Individuals whose screening indicates a severe problem or dependence should be referred to a licensed and certified behavioral health agency for assessment and treatment of a substance use disorder (SUD).

CPT® codes and descriptions only are copyright 2015 American Medical Association

213

Physician-Related Services/Health Care Professional Services

What is covered? SBIRT services are covered for determining risk factors that are related to alcohol and other drug use disorders, providing interventions to enhance patient motivation to change, and making appropriate referrals as needed. SBIRT screening will occur during an E/M exam and is not billable with a separate code. A brief intervention may be provided on the same day as a screening and billed in addition to the E/M exam. Brief interventions may also be performed on subsequent days. Brief interventions are limited to four sessions per patient, per provider per calendar year. Procedure Code

Short Description

CPT 99408

Brief intervention for alcohol and substance abuse; 15 to 30 minutes

CPT 99409

Brief intervention for alcohol and substance abuse; greater than 30 minutes

SBIRT services will be covered by the agency when all of the following are met:     

The billing provider and servicing provider have submitted their SBIRT certification to the agency The billing provider has an appropriate taxonomy to bill for SBIRT The diagnosis code is Z71.41 or Z71.51 The treatment or brief intervention does not exceed the limit of four (4) encounters per client, per provider, per year The SBIRT assessment, intervention, or treatment takes places in one of the following places of service:         

Office Urgent care facility Outpatient hospital Emergency room – hospital Federally qualified health center (FQHC) Community mental health center Indian health service – free standing facility Tribal 638 free standing facility Homeless shelter

CPT® codes and descriptions only are copyright 2015 American Medical Association

214

Physician-Related Services/Health Care Professional Services

Who is eligible to become a certified SBIRT provider? The following categories of licensed or certified health care professionals are eligible to become certified to provide or supervise staff that provides SBIRT services.            

Advanced registered nurse practitioners, in accordance with chapter 18.79 RCW and chapter 246-840 WAC Chemical dependency professionals, in accordance with chapter 18.205 RCW and chapter 246-811 WAC Licensed practical nurse, in accordance with chapter 18.79 RCW and chapter 246-840 WAC Mental health counselor, in accordance with chapter 18.225 RCW and chapter 246-809 WAC Marriage and family therapist, in accordance with chapter 18.225 RCW and chapter 246809 WAC Independent and advanced social worker, in accordance with chapter 18.225 RCW and chapter 246-809 WAC Physician, any specialty, in accordance with chapter 18.71 RCW and chapter 246-919 WAC Physician assistant, in accordance with chapter 18.71A RCW and chapter 246-918 WAC Psychologist, in accordance with chapter 18.83 RCW and chapter 246-924 WAC Registered nurse, in accordance with chapter 18.79 RCW and chapter 246-840 WAC Dentist, in accordance with chapter 18.260 and chapter 246-817 WAC Dental hygienists, in accordance with chapter 18.29 and chapter 246-815 WAC

What are the requirements to be a certified SBIRT provider? SBIRT services must be provided by or under the supervision of a certified physician or other certified licensed health care professional. SBIRT services may be provided by a certified health care professional under supervision of and as recommended by a certified physician or licensed health care professional within the scope of their practice.

Required training All licensed health care professionals must be trained in order to provide or supervise individuals providing SBIRT Services. Licensed health care professionals must complete a minimum of four (4) hours of SBIRT training approved by the agency. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Training is available through a variety of entities. Distance learning is industry-recognized education obtained through sources such as internet course work, satellite downlink resources, or online courses. Agency-approved training is available through the following:     

Washington State Social and Health Services (DSHS) Division of Behavioral Health and Recovery Washington State Department of Health (DOH) Washington State Health Care Authority (HCA) Northwest Addiction Technology Transfer Center Institutions of higher learning that are accredited by a national or regional accrediting body recognized by the Commission on Recognition of Postsecondary Accreditation

Other resources for training events are listed at the following: 

Department of Social and Health Services Division of Behavioral Health and Recovery Training and Events



Washington State SBIRT-Primary Care Integration Program



Northwest Addiction Technology Transfer Center



Substance Abuse and Mental Health Services Administration SBIRT: Training and Other Resources

All health care professionals must document successful training of an approved course of training in order to bill for services. This documentation will be used to identify the health care professional through his/her National Provider Identifier (NPI) number for billing services. Providers who are already enrolled and have completed the training must update their provider profile in ProviderOne with the training certificate or other proof of completion. Mail or fax certificate to: Provider Enrollment PO Box 45562, Olympia, WA 98504-5562 Fax: 360-725-2144 Health care professionals who are not enrolled with the agency, but who are licensed and have completed the training, may enroll as a Washington Apple Health (Medicaid) provider to offer this service.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

What are the billing requirements for SBIRT services? The provider can bill for this service as long as the service is in a primary care setting, including a dentist office. Any other treatment services provided by a chemical dependency professional must be delivered and billed in accordance with chapter 246-811 WAC. The table below clarifies what a primary care setting may include. Primary Care Physician ARNP, PA RN, LPN Dentist Dental hygienist Licensed Mental Health Care Provider

Integrated Primary Care Physician ARNP, PA RN, LPN Social Worker Chemical Dep. Professional Marriage and Family Therapist Psychologist Mental Health Counselor

Who can bill for SBIRT services? The following is a list of providers who can bill for SBIRT services when properly certified:        

Advanced registered nurse practitioners Mental health counselors Marriage and family therapists Independent and advanced social workers Physicians (any specialty) Psychologists Dentists Dental hygienists

CPT® codes and descriptions only are copyright 2015 American Medical Association

217

Physician-Related Services/Health Care Professional Services

Alcohol and Substance Abuse Treatment Services Medical services for clients in residential chemical dependency treatment The agency will pay medical professionals (within their scope of practice) for the following services when the practitioner provides services at a Residential Chemical Dependency Treatment Center (place of service 55). Service E/M services Basic Laboratory Services (e.g., dipsticks)

Procedure Code 99201-99205; 99211-99215 81000, 81002; 81025, 82948

Venipuncture

36415

Notes

Lab specimens processed in the provider’s office must be billed in POS 11; Labs specimens processed in a laboratory should be billed in POS 81.

Clients requiring additional nonemergency medical services such as wound care must go to the provider’s office or another medical setting.

Detoxification services The agency covers detoxification services for clients receiving alcohol and/or drug detoxification services in a Division of Behavioral Health and Recovery (DBHR)-enrolled hospital-based detoxification center or in an acute care hospital when the following conditions are met: 

The stay meets the intensity of service and severity of illness standards necessary to qualify for an inpatient hospital stay.



The care is provided in a medical unit.



The client is not participating in the agency’s Chemical-Using Pregnant (CUP) Women program. CPT® codes and descriptions only are copyright 2015 American Medical Association

218

Physician-Related Services/Health Care Professional Services 

Inpatient psychiatric care is not medically necessary and an approval from the Behavioral Health Organization (BHO) is not appropriate.



Nonhospital-based detoxification is not medically appropriate. Note: Physicians must indicate the hospital’s NPI in field 32 on the CMS-1500 claim form (version 02/12) or in the Comments field when billed electronically. If the hospital’s NPI is not indicated on the claim, the claim will be denied.

When the conditions above are met, providers must bill as follows: Procedure Code

Modifier

H0009

H0009

Short Description Alcohol and/or drug services [bill for the initial admission] Alcohol and/or drug services with follow-up service modifier [bill for any follow-up days]

TS

Limitations Limited to one per hospitalization. Restricted to the appropriate ICD diagnosis codes. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

Note: Managed care clients who are receiving detoxification services in a detoxification hospital that has a detoxification-specific taxonomy can be billed directly to the agency.

CPT® codes and descriptions only are copyright 2015 American Medical Association

219

Physician-Related Services/Health Care Professional Services

Blood, blood products, and related services Whole blood and components (red cells, plasma, platelets, cryoprecipitate) are used in the treatment of a wide variety of conditions. Blood products are therapeutic substances derived from human blood or plasma and produced by a manufacturing process. Blood products are also used to treat a wide variety of conditions. Examples of blood products are plasma derivatives such as:   

Albumin Coagulation factors Immunoglobulins

Payment for blood and blood products 

The agency does not pay for blood or blood products that are donated.



The agency pays for the covered service charges necessary in handling and processing blood and blood products. Procedure Code 36415 36416 36430 36450 36511 36512 36516 36522 38205 38206 38207 38208 38209 38210 38211 38212 38213

Modifier

Short Description Routine venipuncture Capillary blood draw Blood transfusion service Bl exchange/transfuse nb Apheresis wbc Apheresis rbc Apheresis, selective Photopheresis Harvest allogenic stem cell Harvest auto stem cells Cryopreserve stem cells Thaw preserved stem cells Wash harvest stem cells T-cell depletion of harvest Tumor cell deplete of harvest Rbc depletion of harvest Platelet deplete of harvest

EPA/PA

Policy/ Comments

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220

Physician-Related Services/Health Care Professional Services Procedure Code 38214 38215 78120 78120 78120 78121 78121 78121 82143 82247 82248 82668 82784 82803 83020 83020 83030 84460 85002 85013 85014 85018 85032 85049 85130 85210 85220 85230 85240 85245 85246 85247 85250 85260 85270 85280 85290 85291 85292 85293 85300 85301

Modifier

26 TC 26 TC

26

Short Description Volume deplete of harvest Harvest stem cell concentrate Red cell mass single Red cell mass single Red cell mass single Red cell mass multiple Red cell mass multiple Red cell mass multiple Amniotic fluid scan Bilirubin total Bilirubin direct Assay of erythropoietin Assay, iga/igd/igg/igm each Blood gases any combination Hemoglobin electrophoresis Hemoglobin electrophoresis Fetal hemoglobin chemical Alanine amino (ALT) (SGPT) Bleeding time test Spun microhematocrit Hematocrit Hemoglobin Manual cell count each Automated platelet count Chromogenic substrate assay Clot factor ii prothrom spec Blood clot factor v test Clot factor vii proconvertin Clot factor viii ahg 1 stage Clot factor viii vw ristoctn Clot factor viii vw antigen Clot factor viii multimetric Clot factor ix ptc/chrstmas Clot factor x stuart-power Clot factor xi pta Clot factor xii Hageman Clot factor xiii fibrin stab Clot factor xiii fibrin scrn Clot factor fletcher fact Clot factor wght kininogen Antithrombin iii activity Antithrombin iii antigen

EPA/PA

Policy/ Comments

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221

Physician-Related Services/Health Care Professional Services Procedure Code 85302 85303 85305 85306 85307 85335 85362 85366 85370 85378 85384 85385 85410 85420 85421 85460 85461 85475 85520 85576 85576 85597 85610 85635 85660 85670 85705 85730 85732 85999 86021 86022 86023 86078 86317 86329 86592 86593 86644 86645 86687 86688

Modifier

26

Short Description Clot inhibit prot c antigen Clot inhibit prot c activity Clot inhibit prot s total Clot inhibit prot s free Assay activated protein c Factor inhibitor test Fibrin degradation products Fibrinogen test Fibrinogen test Fibrin degrade semiquant Fibrinogen activity Fribrinogen antigen Fibrinolytic antiplasminogen Fibrinolytic plasminogen Fibrinolytic plasminogen Hemoglobin fetal Hemoglobin fetal Hemolysin acid Heparin assay Blood platelet aggregation Blood platelet aggregation Phospholipid pltlt neutraliz Prothrombin time Reptilase test RBC sickle cell test Thrombin time, plasma Thromboplastin inhibition Thromboplastin time partial Thromboplastin time partial Hematology procedure WBC antibody identification Platelet antibodies Immunoglobulin assay Phys blood bank serv reactj Immunoassay infectious agent Immunodiffusion nes Syphilis test non-trep qual Syphilis test non-trep quant CMV antibody CMV antibody IgM Htlv-i antibody Htlv-ii antibody

EPA/PA

Policy/ Comments

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222

Physician-Related Services/Health Care Professional Services Procedure Code 86689 86701 86702 86703 86704 86705 86706 86711 86793 86803 86804 86805 86807 86821 86828 86829 86830 86831 86832 86833 86834 86835 86849 86850 86860 86870 86880 86885 86886 86890 86891 86900 86901 86902 86904 86905 86906 86920 86921 86922 86923 86927

Modifier

Short Description Htlv/hiv confirmj antibody Hiv-1antibody Hiv-2 antibody Hiv-1/hiv-2 1 result antbdy Hep b core antibody total Hep b core antibody igm Hep b surface antibody John cunningham antibody Yersinia antibody Hepatitis c ab test Hep c ab test confirm Lymphocytotoxicity assay Cytotoxic antibody screening Lymphocyte culture mixed Hla class i&ii antibody qual Hla class i/ii antibody qual Hla class i phenotype qual Hla class ii phenotype qual Hla class i high defin qual Hla class ii high defin qual Hla class i semiquant panel Hla class ii semiquant panel Immunology procedure RBC antibody screen RBC antibody elution RBC antibody identification Coombs test Coombs test indirect qual Coombs test indirect titer Autologous blood process Autologous blood op salvage Blood typing abo Blood typing rh (d) Blood type antigen donor ea Blood typing patient serum Blood typing rbc antigens Blood typing rh phenotype Compatibility test spin Compatibility test incubate Compatibility test antiglob Compatibility test electric Plasma fresh frozen

EPA/PA

Policy/ Comments

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Physician-Related Services/Health Care Professional Services Procedure Code 86930 86931 86932 86940 86941 86945 86950 86960 86965 86970 86971 86972 86975 86976 86977 86978 86985 86999 87340 87390 87391 87449 90281 90283 90287 90288 90291 90296 90371 90375 90376 90378 90384 90385 90386 90389 90396 90399 96360 96361 96365 96366

Modifier

Short Description Frozen blood prep Frozen blood thaw Frozen blood freeze/thaw Hemolysins/agglutinins auto Hemolysins/agglutinins Blood product/irradiation Leukacyte transfusion Vol reduction of blood/prod Pooling blood platelets Rbc pretx incubatj w/chemical Rbc pretx incubatj w/enzymes Rbc pretx incubatj w/density Rbc serum pretx incubj drugs Rbc serum pretx id dilution Rbc serum pretx incubj/inhib Rbc pretreatment serum Split blood or products Transfusion procedure Hepatitis b surface ag eia Hiv-1 ag eia Hiv-2 ag eia Ag detect nos eia mult Human ig im Human ig iv Botulinum antitoxin Botulism ig iv Cmv ig iv Diphtheria antitoxin Hep b ig im Rabies ig im/sc Rabies ig heat treated Rsv mab im 50mg Rh ig full-dose im Rh ig minidose im Rh ig iv Tetanus ig im Varicella-zoster ig im Immune globulin Hydration iv infusion init Hydrate iv infusion add-on Ther/proph/diag iv inf init Ther/proph/diag iv inf addon

EPA/PA

Policy/ Comments

CPT® codes and descriptions only are copyright 2015 American Medical Association

224

Physician-Related Services/Health Care Professional Services Procedure Code 96367 +96368 96372 96373 96374 99001 99090 99195 P9010 P9011 P9012 P9016 P9017 P9019 P9020 P9021 P9022 P9023 P9031 P9032 P9033 P9034 P9035 P9036 P9037 P9038 P9039 P9040 P9041 P9043 P9044 P9045 P9046 P9047 P9048 J0850 J1460 J1559 J1560 J1561 J1566 J1568

Modifier

Short Description Tx/proph/dg addl seq iv inf Ther/diag concurrent inf Ther/proph/diag inj sc/im Ther/proph/diag inj ia Ther/proph/diag inj iv push Specimen handling pt-lab Computer data analysis Phlebotomy Whole blood for transfusion Blood split unit Cryoprecipitate each unit RBC leukocytes reduced Plasma 1 donor frz w/in 8 hr Platelets, each unit Platelet rich plasma unit Red blood cells unit Washed red blood cells unit Frozen plasma, pooled, sd Platelets leukocytes reduced Platelets, irradiated Platelets leukoreduced irrad Platelets, pheresis Platelet pheres leukoreduced Platelet pheresis irradiated Plate pheres leukoredu irrad RBC irradiated RBC deglycerolized RBC leukoreduced irradiated Albumin (human),5%, 50ml Plasma protein fract,5%,50ml Cryoprecipitatereducedplasma Albumin (human), 5%, 250 ml Albumin (human), 25%, 20 ml Albumin (human), 25%, 50ml Plasmaprotein fract,5%,250ml Cytomegalovirus imm iv/vial Gamma globulin 1 CC inj Hizentra injection Gamma globulin > 10 CC inj Gamunex-C/Gammaked Immune globulin, powder Octagam Injection

EPA/PA

Policy/ Comments

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Physician-Related Services/Health Care Professional Services Procedure Code J1569 J1599 J1670 J2597 J2790

Modifier

J2791 J2792 J7178 J7197

Short Description Gammagard liquid injection Ivig non-lyophilized, NOS Tetanus immune globulin inj Inj desmopressin acetate Rho d immune globulin inj

EPA/PA

Policy/ Comments

Rhophylac injection Rho(D) immune globulin h, sd Human fibrinogen conc inj Antithrombin iii injection

Fee schedule To view the fee schedules, see the agency’s:  

Physician-Related/Professional Health Care Services Fee Schedule Injectable Drugs Fee Schedule

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Centers of Excellence (WAC 182-531-0650)

List of approved Centers of Excellence (COEs) See the agency’s list of approved COEs for bariatric surgeries, sleep centers, and transplants.

Services which must be performed in a COE Bariatric surgeries (WAC 182-531-1600 and WAC 182-550-2301) Bariatric surgery must be performed in an agency-approved hospital and requires prior authorization (PA). Clients enrolled in an agency-contracted managed care organization (MCO) may be eligible for bariatric surgery. Clients enrolled in an agency-contracted MCO must contact their MCO for information regarding the bariatric surgery benefit.

Clients age 21 through 59 The agency covers medically necessary bariatric surgery for clients 21 through 59 years of age in an approved hospital with a bariatric surgery program in accordance with WAC 182-531-1600. Prior authorization is required. To begin the authorization process, providers must fax the agency a completed Bariatric Surgery Request form, 13-785 (see Resources Available).

Clients age 18 through 20 The agency covers medically necessary bariatric surgery for clients age 18 through 20 years:    

For the laparoscopic gastric band procedure (CPT code 43770). When prior authorized. When performed in an approved hospital with a bariatric surgery program. In accordance with WAC 182-531-1600.

Bariatric case management fee The agency may authorize up to 34 units of a bariatric case management fee as part of the Stage II bariatric surgery approval. One unit of HCPCS code G9012 = 15 minutes of service. Prior authorization is required. CPT® codes and descriptions only are copyright 2015 American Medical Association

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This fee is given to the primary care provider or bariatric surgeon performing the services required for Bariatric Surgery Stage II. This includes overseeing weight loss and coordinating and tracking all the necessary referrals, which consist of a psychological evaluation, nutritional counseling, and required medical consultations as requested by the agency. Clients enrolled in an agency-contracted managed care organization (MCO) must contact their MCO for information regarding coverage of bariatric case management.

Billing Providers must bill with their approved COE facility NPI using the following billing guidelines: 

Electronic billers (837p) must put the COE-approved facility NPI in the Comments field of the electronic claim.



Paper billers must put the COE-approved facility NPI in field 32 on the CMS-1500 claim form (version 02/12). Note: When private insurance or Medicare has paid as primary insurance and the provider is billing the agency as secondary insurance, the agency does not require PA or that the transplant, sleep study, or bariatric surgery be done in a Center of Excellence or agency-approved hospital.

Hemophilia treatment COEs (WAC 182-531-1625) (For administration in the home only) To be paid by the agency for hemophilia and von Willebrand-related products for administration to fee-for-service clients in the home, the products must be provided through an approved hemophilia treatment Center of Excellence (COE). Center of Excellence is defined in WAC 182531-0050. Note: The agency does not require the use of an approved hemophilia treatment COE to obtain hemophilia and von Willebrand-related products when one of the following applies:  The agency is not the primary payer  The client receives the product in an outpatient hospital or clinic setting for nonroutine or urgent care needs  The product is provided by a hemophilia treatment center (HTC) for nonroutine pediatric care and other urgent care needs CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services A hemophilia treatment COE uses a comprehensive care model to provide care for persons with bleeding disorders. The comprehensive care model includes specialized prevention, diagnostic, and treatment programs designed to provide family-centered education, state-of-the-art treatment, research, and support services for individuals and families living with bleeding disorders. Qualified Centers of Excellence (COE) For Hemophilia Treatment are: Puget Sound Blood Center – Seattle Hemophilia Center at Oregon Health Science University (OHSU) – Portland

What criteria must be met to qualify as a COE for hemophilia treatment? To qualify as a COE, a hemophilia treatment center must meet all of the following:    



Have a Core Provider Agreement with the agency Be a federally-approved HTC as defined in WAC 182-531-0050 Meet or exceed all Medical and Scientific Advisory Council (MASAC) standards of care and delivery of services Participate in the public health service 340b provider drug discount program and be listed in the Medicaid Exclusion Files maintained by the federal Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs (OPA) Submit a written request to the agency to be a qualified hemophilia treatment COE and include proof of the following:  



U.S. Center for Disease Control (CDC) and prevention surveillance site identification number Listing in the Hemophilia Treatment Center (HTC) directory

Submit requests to: Hemophilia Treatment COE Health Care Authority–Health Care Services PO Box 45506 Olympia WA 98504-5506



Receive written approval including conditions of payment and billing procedures from the agency

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What documentation is required to continue as a qualified COE for hemophilia treatment? The HTC must annually submit to the agency: 

Copies of grant documents and reports submitted to the Maternal and Child Health Bureau/Human Resources and Services Administration/Department of Health and Human Services or to their designated subcontractors.



Proof of continued federal funding by the National Hemophilia Program and listing with the Regional Hemophilia Network and the CDC.

Are managed care clients required to receive their hemophilia or von Willebrand-related products from a qualified COE? Clients enrolled in a managed care plan must contact their plans for information.

Coverage table Procedure Code J7183 J7185 J7186 J7187 J7189 J7190 J7192 J7193 J7194 J7195 J7198 J7199

Short Description Wilate injection Xyntha inj Antihemophilic viii/vwf comp Humate-P, inj Factor viia Factor viii Factor viii recombinant NOS Factor IX non-recombinant Factor ix complex Factor IX recombinant Anti-inhibitor Hemophilia clotting factor, not otherwise classified

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Sleep studies (WAC 182-531-1500)

Becoming an agency-approved sleep center To become an agency-approved COE, a sleep center must send the following documentation to the Health Care Authority, Provider Enrollment, PO Box 45510, Olympia, WA 98504-5510: 

A completed Core Provider Agreement



Copies of the following: 

The sleep center's current accreditation certificate by AASM



Either of the following certifications for at least one physician on staff:  



Current certification in sleep medicine by the American Board of Sleep Medicine (ABSM) Current subspecialty certification in sleep medicine by a member of the American Board of Medical Specialties (ABMS)

The certification of an RPSGT who is employed by the sleep center

Note: Sleep centers must request reaccreditation from AASM in time to avoid expiration of COE status with the agency. At least one physician on staff at the sleep center must be board certified in sleep medicine. If the only physician on staff who is board certified in sleep medicine resigns, the sleep center must ensure another physician on staff at the sleep center obtains board certification or another boardcertified physician is hired. The sleep center must then send provider enrollment a copy of the physician's board certification. If a certified medical director leaves a COE, the COE status does not transfer with the medical director to another sleep center. The COE must maintain a record of the physician's order for the sleep study. For further information, see sleep medicine testing.

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Transplants (WAC 182-550-1900)

Who is eligible for transplants? The agency pays for medically necessary transplant procedures only for eligible agency clients who are not otherwise subject to a managed care organization (MCO) plan.

Who is not eligible for transplants? Clients eligible under the Alien Emergency Medical (AEM) program are not eligible for transplant coverage.

Which transplant procedures are covered? The agency covers the following transplant procedures when the transplant procedures are performed in a hospital designated by the agency as a Center of Excellence for transplant procedures and meet that hospital's criteria for establishing appropriateness and the medical necessity of the procedures: 

Solid organs involving the heart, kidney, liver, lung, heart-lung, pancreas, kidneypancreas and small bowel The agency pays for a solid organ transplant procedure only once per a client's lifetime, except in cases of organ rejection by the client's immune system during the original hospital stay.



Nonsolid organs include bone marrow and peripheral stem cell transplants

Does the agency pay for skin grafts and corneal transplants? The agency pays for skin grafts and corneal transplants to any qualified hospital when medically necessary.

Does the agency pay for organ procedure fees and donor searches? The agency pays for organ procurement fees and donor searches. For donor searches, CPT codes 86812-86822 are limited to a maximum of 15 tests total for human leukocyte antigens (HLA) typing per client, per lifetime. The agency requires PA for more than 15 tests.

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Physician-Related Services/Health Care Professional Services To bill for donor services: 

Use the client’s ProviderOne Client ID.



Use the appropriate Z52 series diagnosis code as the principal diagnosis code. For example, if billing a radiological exam on a potential donor for a kidney transplant, bill Z52.4 for the kidney donor and use Z00.5 or Z00.8 as a secondary diagnosisexamination of a potential donor. Refer to WAC 182-531-1750, 182-550-1900, 182-5502100, and 182-550-2200. Note: Use of Z00.5 or Z00.8 as a principal diagnosis will cause the line to be denied.

Does the agency pay for experimental transplant procedures? The agency does not pay for experimental transplant procedures. In addition, the agency considers as experimental those services including, but not limited to, the following: 

Transplants of three or more different organs during the same hospital stay.



Solid organ and bone marrow transplants from animals to humans.



Transplant procedures used in treating certain medical conditions for which use of the procedure has not been generally accepted by the medical community or for which its efficacy has not been documented in peer-reviewed medical publications.

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Drugs Professionally Administered (WAC 182-530-2000(1)) The agency covers outpatient drugs, including over-the-counter drugs listed on the agency’s Covered Over-the-Counter Drug list, as defined in WAC 182-530-1050, subject to the limitations and requirements in this section, when: 

The drug is approved by the Food and Drug Administration (FDA).



The drug is for a medically accepted indication as defined in WAC 182-530-1050.



The drug is not excluded from coverage (see WAC 182-530-2000 Covered – Outpatient drugs, devices, and drug related supplies).



The manufacturer has a signed drug rebate agreement with the federal Department of Health and Human Services (DHHS). Exceptions to the drug rebate requirement are described in WAC 182-530-7500 which describes the drug rebate program.

For more information, see the agency’s Prescription Drug Program Provider Guide. Note: The agency requires prior authorization (PA) for all drugs new to market until reviewed by the agency’s Drug Evaluation Matrix Committee according to WAC 182-530-3100. This applies to all products billed under miscellaneous codes or product specific procedure codes. The agency’s fees for injectable drug codes are the maximum allowances used to pay covered drugs and biologicals administered in a provider’s office only.

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Invoice requirements A copy of the manufacturer’s invoice showing the actual acquisition cost of the drug relevant to the date of service must be attached to the claim for drug reimbursed by report (BR) or when billing for compounded drugs. If needed, the agency will request any other necessary documentation after receipt of the claim. A copy of any manufacturer’s invoices for all drugs (regardless of billed charges) must be maintained in the client’s record and made available to the agency upon request.

Drug pricing The agency follows Medicare’s drug pricing methodology of 106% of the Average Sales Price (ASP). If a Medicare fee is unavailable for a particular drug, the agency prices the drug at a percentage of the Average Wholesale Price (AWP). The agency updates the rates each time Medicare’s rate is updated, up to once per quarter. Unlike Medicare, the agency effective dates are based on dates of service, not the date the claim is received. For HCPCS codes where Medicare does not establish a rate, the agency determines the maximum allowances for covered drugs using the following methodology: 1.

For a single-source drug or biological, the AWP equals the AWP of the single product.

2.

For a multi-source drug or biological, the AWP is equal to the median AWP of all of the generic forms of the drug or biological, or the lowest brand-name product AWP, whichever is less. A brand-name product is defined as a product that is marketed under a labeled name that is other than the generic chemical name for the drug or biological.

3.

After determining the AWP according to #1 and #2 above, the agency multiplies the amount by 0.84 to arrive at the fee schedule maximum allowance.

National drug code format All providers are required to use the 11-digit National Drug Code (NDC) when billing the agency for drugs administered in the provider’s office. 

National Drug Code (NDC) – The 11-digit number the manufacturer or labeler assigns to a pharmaceutical product and attaches to the product container at the time of packaging. The 11-digit NDC is composed of a 5-4-2 grouping. The first 5 digits comprise the labeler code assigned to the manufacturer by the Federal Drug Administration (FDA). The second grouping of 4 digits is assigned by the manufacturer CPT® codes and descriptions only are copyright 2015 American Medical Association

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to describe the ingredients, dose form, and strength. The last grouping of 2 digits describes the package size. (WAC 182-530-1050) The NDC must contain 11-digits in order to be recognized as a valid NDC. It is not uncommon for the label attached to a drug’s vial to be missing leading zeros. For example: The label may list the NDC as 123456789when, in fact, the correct NDC is 01234056789. Make sure that the NDC is listed as an 11-digit number, inserting any leading zeros missing from the 5-4-2 groupings, as necessary. The agency will deny claims for drugs billed without a valid 11-digit NDC. Electronic 837-P Claim Form Billing Requirements Providers must continue to identify the drug given by reporting the drug’s CPT or HCPCS code in the PROFESSIONAL SERVICE Loop 2400, SV101-1 and the corresponding 11-digit NDC in DRUG IDENTIFICATION Loop 2410, LIN02 and LIN03. In addition, the units reported in the Units field in PROFESSIONAL SERVICE Loop 2400, SV103 and SV104 must continue to correspond to the description of the CPT or HCPCS code. CMS-1500 Claim Form Billing Requirements When billing using a paper CMS-1500 claim form (version 02/12) for two or fewer drugs on one claim form, list the 11-digit NDC in field 19 of the claim form must be listed exactly as follows (not all required fields are represented in the example): 19. 54569549100 Line 2 / 00009737602 Line 3 Line 1 2 3

Date of Service 07/01/07 07/01/07 07/01/07

Procedure Code 99211 90378 J3420

Charges

Units

50.00 1500.00 60.00

1 2 1

DO NOT attempt to list more than two NDCs in field 19 on the paper CMS-1500 claim form (version 02/12). When billing for more than 2 drugs, list the additional drugs on additional claim forms. Do not bill more than 2 drugs per claim form. If the 11-digit NDC is missing, incomplete, or invalid, the claim line for the drug or supply will be denied.

Physicians billing for compound drugs To bill for compounding of drugs, enter J3490 as the procedure code. Enter the NDC for the main ingredient in the compound on the line level. Put compound in the notes field. Attach an CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services invoice showing all of the products with NDCs and quantities used in the compound. Claims are manually priced per the invoice.

Drugs requiring written/fax prior authorization Drugs requiring written/fax prior authorization are noted in the fee schedule with a PA next to them. For information on how to request prior authorization, refer to Prior Authorization. The agency requires prior authorization for all new drugs to market until reviewed by the agency’s Drug Evaluation Matrix committee according to WAC 182-530-3100. This applies to all products billed under miscellaneous codes or product specific procedure codes. View the list of Drugs Billed Under Miscellaneous HCPCS Codes for drugs that require authorization.

Injectable drugs - limitations Limitations on coverage for certain injectable drugs are listed below, all other diagnoses are noncovered without prior authorization: Procedure Code J0637

Short Description Caspofungin acetate

J0725

Chorionic gonadotropin/1000u

J1050

Injection, Medroxyprogester acetate, 1 mg (depo provera)

J1212 J1595 J1640

Dimethyl sulfoxide 50% 50 ML Injection glatiramer acetate Hemin, 1 mg

J1756 J2323

Iron sucrose injection Natalizumab injection

Limitation Restricted to ICD Dx and/or Dosing B37.81, B44.9, B48.4, B44.2, B44.7, B44.1, B44.0, B44.89 Q53.01, Q53.02, Q53.10, Q53.11, Q53.12, Q53.20, Q53.21, Q53.22, Q53.9, R01.0 Females-only diagnoses Z30.40, Z30.49, Z30.9, Z30.018 allowed once every 67 days. Therapeutic dose for contraception is 150 mg. Males-diagnosis must be related to cancer N30.10, N30.11, N30.20, N30.21 340 G35 (multiple sclerosis) Limited to office or outpatient hospital, females only, 2 vials daily, 8 days per month total. Prior authorization is required for additional days/vials. Effective for dates of service on and after 11/1/2014. N18.1 – N18.9 (chronic kidney disease) Multiple sclerosis G35 Crohn’s disease - See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care

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Limitation Restricted to ICD Dx and/or Dosing Professionals. Requires PA. Use TYSABRI J2323 Request form 13-832 No diagnosis restriction Restricted use only to cardiologists N18.6 (End stage renal disease) N18.6 (End stage renal disease) See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals B44.9, B48.4, B44.2, B44.7, B44.1, B44.0, B44.89 C83.10 – C83.19, C90.00, C90.01 See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals G35 (multiple sclerosis) G35 (multiple sclerosis)

Short Description

J2325

Nesiritide

J2501 J2916 J3285

Paricalcitol Na ferric gluconate complex Treprostinil, 1 mg

J3420

Vitamin B12 injection

J3465

Injection, voriconazole

J9041 J3489

Bortezomib injection Zoledronic acid 1mg

Q3027 Q3028

Inj beta interferon im 1 mcg Inj beta interferon sq 1 mcg

Billing for injectable drugs and biologicals When billing for injectable drugs and biologicals, providers must use the description of the procedure code to determine the units, and include the correct number of units on the claim form to be paid the appropriate amount. For drugs priced at acquisition cost, providers must do one of the following: 

Include a copy of the manufacturer’s invoice for each line item in which billed charges exceed $1,100.00



Retain a copy of the manufacturer’s invoice in the client’s record for each line item in which billed charges are equal to or less than $1,100.00

Do not bill using unclassified or unspecified drug codes unless there is no specific code for the drug being administered. The National Drug Code (NDC) and dosage given to the client must be included with the unclassified or unspecified drug code for coverage and payment consideration. HCPCS codes J8499 and J8999 for oral prescription drugs are not covered. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services Injectable drugs can be injected subcutaneously, intramuscularly, or intravenously. Indicate that the injectable drugs came from the provider's office supply. The name, strength, and dosage of the drug must be documented and kept in the client’s record.

Chemotherapy drugs (J9000-J9999) The following payment guidelines apply to chemotherapy drugs (HCPCS codes J9000-J9999): 

The agency’s maximum allowable fee per unit is based on the HCPCS description of the chemotherapy drug.



The agency follows Medicare’s drug pricing methodology of 106% of the Average Sales Price (ASP). If a Medicare fee is unavailable for a particular drug, the agency continues to price the drug at 84% of the Average Wholesale Price (AWP).



Preparation of the chemotherapy drug is included in the payment for the administration of the drug.



Bill number of units used based on the description of the drug code. For example, if 250 mg of Cisplatin (J9062) is given to the client, the correct number of units is five (5). Note: See Unlisted Drugs for information on when it is necessary to bill the agency for a chemotherapy drug using an unlisted drug code.

Billing for single-dose vials For single-dose vials, bill for the total amount of the drug contained in the vial(s). Based on the unit definition for the HCPCS code, the agency pays providers for the total number of units contained in the vial. For example: If a total of 150 mg of Etoposide is required for the therapy, and two 100 mg single dose vials are used to obtain the total dosage, then the total of the two 100 mg vials is paid. In this case, the drug is billed using HCPCS code J9181 (Etoposide, 10 mg). If the agency’s maximum allowable fee is $4.38 per 10 mg unit, the total allowable is $87.60 (200 mg divided by 10 = 20 units x $4.38). For agency requirements for splitting single dose vials, see Billing for single dose vials (SDV) in the Prescription Drug Program Provider Guide.

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Billing for multi-dose vials For multi-dose vials, bill only the amount of the drug administered to the client. Based on the unit definition (rounded up to the nearest whole unit) of the HCPCS code, the agency pays providers for only the amount of drug administered to the client. For example: If a total of 750 mg of Cytarabine is required for the therapy, and is taken from a 2,000 mg multi-dose vial, then only the 750 mg administered to the client is paid. In this case, the drug is billed using HCPCS code J9110 (Cytarabine, 500 mg). If the agency’s maximum allowable fee is $23.75 per 500 mg unit, the total allowable is $47.50 [750 mg divided by 500 = 2 (1.5 rounded) units x $23.75].

Billing for oral anti-emetic drugs when part of a chemotherapy regimen In order to bill the agency for oral anti-emetic drugs (HCPCS codes Q0162-Q0181), the drug must be: 

Part of a chemotherapy regimen.



Administered or prescribed for use immediately before, during, or within 48 hours after administration of the chemotherapy drug.



Billed using the appropriate ICD cancer diagnoses.



Submitted on the same claim form with one of the chemotherapy drug codes (HCPCS codes J8530-J9999).

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Rounding of units The following guidelines should be used to round the dosage given to the client to the appropriate number of units for billing purposes: I.

Single-Dose Vials:

For single-dose vials, bill the total amount of the drug contained in the vial(s), including partial vials. Based on the unit definition for the HCPCS code, the agency pays providers for the total number of units contained in the vial. For example: If a total of 150 mg of Etoposide is required for the therapy and two 100 mg single dose vials are used to obtain the total dosage, the total of the two 100 mg vials is paid. In this case, the drug is billed using HCPCS code J9181 (Etoposide, 10 mg). If the agency’s maximum allowable fee is $4.38 per 10 mg unit, the total allowable is $87.60 (200 mg divided by 10 = 20 units x $4.38).

II.

Billing for Multi-Dose Vials:

For multi-dose vials, bill only the amount of the drug administered to the client. Based on the unit definition (rounded up to the nearest whole unit) of the HCPCS code, the agency pays providers for only the amount of drug administered to the client. For example: If a total of 750 mg of Cytarabine is required for the therapy and is taken from a 2,000 mg multidose vial, only the 750 mg administered to the client is paid. In this case, the drug is billed using HCPCS code J9110 (Cytarabine, 500 mg). If the agency’s maximum allowable fee is $23.75 per 500 mg unit, the total allowable is $47.50 [750 mg divided by 500 = 2 (1.5 rounded) units x $23.75].

Unlisted drugs (HCPCS J3490, J3590, and J9999) When it is necessary to bill the agency for a drug using an unlisted drug code, providers must report the National Drug Code (NDC) of the drug administered to the client. The agency uses the NDC when unlisted drug codes are billed to appropriately price the claim. To be reimbursed: 

Claims must include:   

The dosage (amount) of the drug administered to the client. The 11-digit NDC of the office-administered drug. One unit of service. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

The drug must be approved by the Food and Drug Administration (FDA).



The drug must be for a medically accepted indication as defined in WAC 182-530-1050 (see WAC 182-530-2000 Covered – Outpatient drugs, devices, and drug related supplies).



The drug must not be excluded from coverage.



For claims billed using a paper CMS-1500 claim form (version 02/12), list the required information in field 19 of the claim form.



For claims billed using an electronic CMS-1500 claim form (version 02/12), list the required information in the Comments section of the claim form.



For claims billed using an electronic 837P claim form, list the required NDC information in DRUG IDENTIFICATION Loop 2410, LIN02, and LIN03. List the dosage given to the client in the Comments section of the claim form.

See Vaccines/Toxoids (Immunizations) for more detailed information on NDC billing. Note: If there is an assigned HCPCS code for the administered drug, providers must bill the agency using the appropriate HCPCS code. Do not bill using an unlisted drug code for a drug that has an assigned HCPCS code. The agency will recoup payment for drugs paid using an unlisted drug code if an assigned HCPCS code exists for the administered drug. The list of all injectable drug codes and maximum allowable fees are listed in the Injectable Drugs Fee Schedule.

Botulinum toxin injections (Botox) (HCPCS code J0585, J0586, J0587, J0588, and CPT codes 52287 and 64615) The agency requires prior authorization for the following procedure codes: 

HCPCS codes J0585, J0586, J0587, J0588 and CPT codes 52287 and 64615 regardless of the diagnosis



CPT code 95874 when needle electromyography is used for guidance during the injection

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Physician-Related Services/Health Care Professional Services Submission of an authorization request must be in writing on the General Information for Authorization (13-835) form along with a completed Botulinum Toxin Provider Questionnaire (13-003) form.

Collagenase injections (HCPCS code J0775, CPT codes 20527 and 26341) The agency requires prior authorization for HCPCS code J0775, CPT codes 20527 and 26341.

Hyaluronic acid/viscosupplementation The agency covers hyaluronic acid/viscosupplementation for the treatment of pain associated with osteoarthritis of the knee (OA), as follows: 

Restricted to clients who have a documented medical contraindication to other forms of nonsurgical care including all of the following: NSAIDS, corticosteroid injections and physical therapy/exercise



Performed by an orthopedic surgeon, rheumatologist, or physiatrist only



Limited to two courses per year with at least four months between courses



Documented evidence of clinical benefit in terms of pain and function from the prior course of treatment is required for subsequent treatment courses

Bill for the injectable drug after all injections are completed. HCPCS Code J7321

Short Description Hyalgan/supartz inj per dose

J7323

Euflexxa inj per dose

J7324

Orthovisc inj per dose

J7325

Synvisc inj per dose

J7326

Gel-One inj per

Limitations Five injections (1 week apart) covers a full course of treatment per knee. Maximum of two courses of treatment per year, per knee, at least four months apart Three to four injections (1 week apart) covers a full course of treatment per knee. Maximum of two courses of treatment per year, per knee, at least four months apart. Three to four injections (1 week apart) covers a full course of treatment per knee. Maximum of two courses of treatment per year, per knee, at least four months apart. One unit equals one mg. Full course of treatment is 3 injections per knee, one week apart. Limited to 2 courses of treatment per knee, per year, at least four months apart. Maximum of 48 units per knee, per course of treatment. Maximum of 2 injections per year, per knee at least 4

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Short Description Limitations dose months apart Note: The agency requires PA for any off label use of these products. Failure to obtain PA will result in denied payment or recoupment.

Hyaluronic acid/viscosupplementation injections are covered only with the following ICD diagnosis codes: Diagnosis Code M17.0, M17.9, M17.10, M17.11, M17.12, M13.861, M13.862, M13.869 M13.861, M13.862, M13.869 M17.9, M13.861, M13.862, M13.869 M13.861, M13.862, M13.869

Description Osteoarthritis, localized, primary lower leg.

Osteoarthritis, localized, secondary, lower leg. Osteoarthritis, localized, not specified whether primary or secondary, lower leg. Osteoarthritis, unspecified whether generalized or localized, lower leg.



The injectable drugs must be billed after all injections are completed.



Bill CPT injection code 20610 each time an injection is given, up to a maximum of 5 per knee, per course of treatment.



Bill both the injection CPT code and HCPCS drug code on the same claim form.

Alpha Hydroxyprogesterone (17P) The agency will cover the use of Alpha Hydroxyprogesterone (17P) as one strategy to reduce the incidence of premature births. The American College of Obstetricians and Gynecologists (ACOG) has indicated that 17P may be of benefit to pregnant women with:  

A singleton gestation. A history of prior spontaneous preterm delivery (between 20 weeks gestation and 36 weeks, 6 days gestation) which was either:  

Due to preterm labor. A spontaneous delivery due to unknown etiology.

The agency will reimburse administering providers (with the exception of hospitals) without prior authorization for 17P and its administration as follows: CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services   

17P must be purchased by the provider from a sterile compounding pharmacy The compound is individually produced on a client-by-client basis One dose per week is covered during week 16 through week 36 of pregnancy

How to bill for Alpha Hydroxyprogesterone (17P) When billing for 17P (HCPCS code J3490), enter the following information on the claim:  

The NDC for the main ingredient in the compound on the line level The word Compound in the Notes field

Attach to the claim the invoice from the pharmacy showing all of the products with NDCs and quantities used in the compound.

Makena® The commercially marketed form of 17P is Makena® (HCPCS code J1725). Providers may administer Makena® in an office setting and are reimbursed by the agency for the administration only. The agency reimburses the dispensing pharmacy for Makena® with prior authorization from the agency. Authorization for reimbursement to a dispensing pharmacy for Makena® requires documented medical justification of the reason an individually compounded form of 17P is not appropriate for the client.

Prolia/Xgeva The agency covers denosumab injection (Prolia® and Xgeva®) as follows:  

Prior authorization is required Providers bill the agency using HCPCS code J0897

When submitting the General Information for Authorization (13-835) form to request PA, field 15 must contain the brand name (Prolia® or Xgeva®) of the requested product. The agency will reject requests for J0897 without this information. Providers must complete all other required fields.

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Synagis® What are the requirements for administration and authorization of Synagis®? (CPT code 90378) The agency requires providers to following the guidelines and standards as published in The Official Journal of the American Academy of Pediatrics, Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection for clients considered for Synagis® prophylaxis during the RSV season. Note: This information relates only to those clients NOT enrolled in an agencycontracted managed care organization (MCO). For clients enrolled in an agencycontracted MCO, refer to the coverage guidelines in the enrollee’s plan.

Respiratory syncytial virus (RSV) Season The agency has established the RSV season as December through April. The agency monitors RSV incidence as reported by laboratories throughout the state and may change the dates based on the data collected. Unless otherwise notified by the agency, these dates are firm.

Criteria for the administration of Synagis® to agency clients The agency requires that the following guidelines and standards of care be applied to clients considered for Synagis® prophylaxis during the RSV season. The agency established these guidelines and standards as published in The Official Journal of the American Academy of Pediatrics, “Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.”

Are there other considerations when administering Synagis®? Administer the first dose of Synagis® 48 to 72 hours before discharge or promptly after discharge to infants who qualify for prophylaxis during the RSV season. If an infant or child who is receiving Synagis® immunoprophylaxis experiences a breakthrough RSV infection, continue administering monthly prophylaxis for the maximum allowed doses as above. Note: The agency does not authorize Synagis® for children with cystic fibrosis. CPT® codes and descriptions only are copyright 2015 American Medical Association

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What are the authorization and billing procedures for Synagis®? Direct questions or concerns regarding billing and authorization of Synagis® to the agency at (800) 562-3022. Fax prior authorization requests on completed agency prior authorization form(s) to (866) 668-1214. Bill the agency for Synagis® using the following guidelines: 

Synagis® may be dispensed and billed by a retail pharmacy for administration by a physician, or may be billed by the physician’s office.



Pharmacies bill through standard pharmacy Point-of-Sale electronic claim submission using the appropriate National Drug Code for the product dispensed.



Physician’s offices billing directly for Synagis® must bill on a CMS-1500 claim form (version 02/12) or comparable electronic billing format using CPT code 90378.



To bill for the administration of Synagis® use CPT code 90471 or 90472 if:  

Dispensed through the pharmacy POS. Administered through the physician’s office.

What is the criteria for coverage or authorization of Synagis®? Note: Criteria for coverage or authorization vary depending on the patient’s age. 

Children younger than one year of age The agency requires providers to use and accurately apply the criteria for administration of Synagis® to agency clients. Billing for Synagis® outside of the guidelines mentioned in the Official Journal of the American Academy of Pediatrics will be considered an overpayment and will be subject to recoupment. The agency will continue to cover Synagis for clients younger than one year of age without authorization, as long as utilization is appropriate. In this case, physicians and pharmacies are not required to submit paperwork or obtain pre-approval for the administration of Synagis.



Children age 1 and 2

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Physician-Related Services/Health Care Professional Services Prior authorization is required to administer Synagis to agency clients age 1 and 2. Request authorization by faxing the Request for Synagis (13-771) form. 

Children age 3 and older The agency does not pay for administering Synagis® to clients age 3 and older.

What are the authorization procedures for Synagis? 



Pharmacy billers 

Pharmacies must submit a request for authorization using the agency’s Pharmacy Information Authorization (13-835A) form as the cover sheet. This form must be typed.



Fax the form to the agency at: (866) 668-1214. If authorized, the agency may approve the 100mg strength, the 50mg strength, or both. However, pharmacies must use National Drug Code (NDC) 60574-4113-01 in box #21 on Pharmacy Information Authorization form (13-835A). After the agency reviews your request, you will receive notification by fax of strengths, quantities, and NDC(s) approved.



The Request for Synagis (13-771) form must accompany a typed Pharmacy Information Authorization form (13-835A) as supporting documentation.



Pharmacies billing for Synagis® through standard pharmacy Point-of-Sale electronic claim submission must use the appropriate National Drug Code for the product dispensed.

Physician office billers 

Physician offices must submit a request for authorization using the agency’s General Information for Authorization form (13-835) as the cover sheet. This form must be typed.



The agency’s Request for Synagis® form (13-771) must be submitted as supporting documentation in addition to the General Information for Authorization form (13-835).



Physician offices billing the agency directly for Synagis® must bill using a CMS1500 claim form (version 02/12) or comparable electronic billing format using CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services CPT code 90378. After the agency reviews your request, you will receive notification by fax of the total milligrams and NDC(s) approved.



Requesting an increase in Synagis® dose The quantity of Synagis® authorized for administration is dependent upon the weight of the client at the time of administration. If you obtained authorization for a quantity of Synagis® that no longer covers the client’s need due to weight gain: 

Complete the appropriate ProviderOne Cover Sheet by entering the initial authorization number.  



Pharmacy billers use the Pharmacy PA Supporting Docs sheet. Physician office billers use PA (Prior Authorization) Pend Forms sheet.

Complete the Request for Additional MG's of Synagis® Due to Client Weight Increase (HCA 13-770) form and submit along with the ProviderOne Cover Sheet.

The agency will update the authorization to reflect an appropriate quantity and return a fax to the requestor confirming the increased dosage. See the Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.



Evaluation of authorization requests for Synagis® The agency physicians will evaluate requests for authorization to determine whether the client falls within 2014 AAP guidelines for the administration of Synagis®. The agency will fax an approval or denial to the requestor. Allow at least five business days for the agency to process the authorization request. You may verify the status of a pending authorization by using the ProviderOne PA Inquire feature.

Verteporfin injection (HCPCS code J3396) Verteporfin injections are limited to ICD diagnosis codes H35.30 and H35.32.

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Vivitrol (HCPCS J2315) The agency requires prior authorization for Vivitrol. It is also available when prior authorized through the pharmacy Point-of Sale (POS) system. Note: When requesting prior authorization, use the agency’s Medication Assisted Treatment Request for IM Naltrexone (HCA 13-331) form if a client requires medication-assisted treatment for less than six months. If a client requires medication assisted treatment beyond six months, the provider must complete the agency’s Medication Assisted Treatment (HCA 13-333) form and keep the completed form in the client’s file. This form must be completed for each additional six months of treatment.

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Foot Care Services (WAC 182-531-1300) This section addresses care of the lower extremities (foot and ankle) referred to as foot care and applies to clients age 21 and older. Note: Care of the lower extremity is defined as foot and ankle care.

Are foot care services covered? The agency covers foot care services for clients age 21 and older as listed in this section when those services are provided by any of the following health care providers and billed to the agency using procedure codes and diagnosis codes that are within their scope of practice:    

Physicians and surgeons or physician's assistants-certified (PA-C) Osteopathic physicians and surgeons, or physician's assistant-certified (PA-C) Podiatric physicians and surgeons Advanced registered nurse practitioners (ARNP)

The agency covers evaluation and management visits to assess and diagnose conditions of the lower extremities. Once diagnosis is made, the agency covers treatment if the criteria in WAC 182-531-1300 (4)(a) are met.

What foot care services does the agency pay for? The agency considers treatment of the lower extremities to be medically necessary only when there is an acute condition, an exacerbation of a chronic condition, or presence of a systemic condition such as metabolic, neurologic, or peripheral vascular disease and evidence that the treatment will prevent, cure or alleviate a condition in the client that causes pain resulting in inability to perform activities of daily living, acute disability, or threatens to cause the loss of life or limb, unless otherwise specified. (WAC 182-531-1300 (4)(a)) Note: Providers may request an exception to rule (ETR) for treatment of those conditions not described in this section. See WAC 182-501-0160 Exception to rule – Request for a noncovered health care service.

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Physician-Related Services/Health Care Professional Services The agency pays for: 

Treatment of acute inflammatory processes such as: 

Circulatory compromise such as, but not limited to:  Lymphedema.  Raynaud's disease.  Thromboangiitis obliterans.  Phlebitis.

       

Charcot Arthropathy. Gout. Injuries, fractures, sprains, and dislocations. Lacerations, ulcerations, wounds, blisters. Neuropathies, e.g., reflex sympathetic dystrophy secondary to diabetes. Osteomyelitis. Postoperative complications. Tendonitis.



Removal of warts, corns, or calluses in the presence of an acute condition such as infection and pain affecting the client’s ability to ambulate as a result of the warts, corns or calluses for an allowable condition.



Treatment of soft tissue conditions, such as, but not limited to:      

Rashes. Infections (fungal, bacterial). Gangrene. Cellulitis of lower extremities. Soft tissue tumors. Neuroma.



Treatment of nail bed infections (paronychia).



Treatment of tarsal tunnel syndrome.



Treatment of diabetic foot ulcers with Theraskin when prior authorization is obtained. See Authorization.



Trimming and/or debridement of nails to treat an allowable condition.



The agency pays for one treatment in a 60-day period. The agency covers additional treatments in this period if documented in the client's medical record as being medically necessary. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services  

A surgical procedure to treat one of the allowable conditions. Impression casting to treat one of the allowable conditions.



Custom fitted and/or custom molded orthotic devices to treat one of the allowable conditions. 

The agency's fee for the orthotic device includes reimbursement for a biomechanical evaluation (an evaluation of the foot that includes various measurements and manipulations necessary for the fitting of an orthotic device).



The agency includes an evaluation and management (E/M) fee reimbursement in addition to an orthotic fee reimbursement if the E/M services are justified and well documented in the client's medical record.

The agency includes 90-day follow-up care in the reimbursement.

Allowable conditions of the lower extremities by diagnosis See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals.

What foot care services does the agency not pay for? The agency does not pay for: Treatment of or follow-up office visits for chronic acquired conditions of the lower extremities. The agency pays for prescriptions using the criteria found in the Prescription Drug Program Provider Guide. Foot care, unless the client meets criteria and conditions outlined in WAC 182-531-1300 as follows: 

Routine foot care, such as but not limited to:   

Cutting or removing warts, corns and calluses Treatment of tinea pedis Trimming, cutting, clipping, or debriding of nails CPT® codes and descriptions only are copyright 2015 American Medical Association

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Nonroutine foot care, such as, but not limited to treatment of:         



Adult acquired flatfoot (metatarsus adductus or pes planus) Bunions and tailor's bunion (hallux valgus) Cavovarus deformity, acquired Equinus deformity of foot, acquired Flat feet High arches (cavus foot) Hallux malleus Hallux limitus Onychomycosis

Any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

The agency does not pay for the following radiology services:   

Bilateral X-rays for a unilateral condition X-rays in excess of three views X-rays that are ordered before the client is examined

The agency does not pay podiatric physicians or surgeons for X-rays for any part of the body other than the foot or ankle.

May I bill the client for foot care services which the agency does not pay for? A waiver is required when clients choose to pay for a foot care service to treat a condition not listed in the Allowable Conditions of the Lower Extremities by Diagnosis table. Requesting an ETR is optional for the client. See WAC 182-502-0160, Billing the Client for details.

How do I bill for foot care services? The agency will pay for treatment of an acute condition only when the condition is the primary reason for the service. This must be documented in the client’s record. When billing, the diagnosis code for the acute condition listed in the Allowable Conditions of the Lower Extremities by Diagnosis table must be on the service line for the foot care service being billed.

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Physician-Related Services/Health Care Professional Services If the description of the orthotic code indicates the code is for a single orthotic or impression casting of one foot, either modifier RT or LT must be included on the claim. Providers must use an appropriate procedure code with the word "pair" in the description when billing for fabrications, casting, or impressions of both feet. The agency pays for an Evaluation and Management (E/M) code and an orthotic on the same day if the E/M service performed has a separately identifiable diagnosis and the provider bills using modifier 25 to indicate a significant and separately identifiable condition exists and is reflected by the diagnosis. If Medicare does not cover orthotics and casting, providers may bill the agency directly for those services without submitting a Medicare denial, unless the client's eligibility check indicates QMB - Medicare only, in which case the orthotics and casting is not covered by the agency. If Medicare does cover the service, bill Medicare first.

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Physician-Related Services/Health Care Professional Services

Hospice Physicians providing service to hospice clients The agency pays providers who are attending physicians and not employed by the hospice agency:   

For direct physician care services provided to a hospice client When the provided services are not related to the terminal illness When the client’s provider, including the hospice provider, coordinates the health care provided

Concurrent care for children who are on hospice (WAC 182-551-1860) In response to the Patient Protection and Affordable Care Act, clients age 20 and younger who are on hospice service are also allowed to have access to curative services. Note: The legal authority for these clients’ hospice palliative services is Section 2302 of the Patient Protection and Affordable Care Act of 2010 and Section 1814(a)(7) of the Social Security Act; and for client’s curative services is Title XIX Medicaid and Title XXI Children's Health Insurance Program (CHIP) for treatment of the terminal condition.

Concurrent/curative treatment Unless otherwise specified within this provider guide, concurrent/curative treatment, related services, or related medications requested for clients age 20 and younger are subject to the agency’s specific program rules governing those services or medications. The treating medical providers must request these services, including treatment planning, actual treatment, and related medications, through the agency’s prior authorization (PA) process. Prior authorization requests for concurrent/curative treatment or medications are subject to medical necessity review under WAC 182-501-0165. The Medicaid agency will notify the hospice agency when there is an approval or denial for hospice curative treatment. It is the hospice agency's responsibility to continue to coordinate care.

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Services included under the agency’s concurrent/curative care benefit The following services aimed at achieving a disease-free state are included under the curative care benefit paid for by the agency:         

Radiation Chemotherapy Diagnostics, including laboratory and imaging Licensed health care professional services Inpatient and outpatient hospital care Surgery Medication Equipment and related supplies Ancillary services, such as medical transportation

Authorization for concurrent/curative services The agency requires authorization for all concurrent/curative care. Providers must request authorization for these services, including a comprehensive treatment plan, ancillary services, and related medications. Prior authorization requests for concurrent/curative treatment and medications are subject to medical necessity review under WAC 182-501-0165.

Note: See How do I request prior authorization or limitation extensions? for the documentation required for prior authorization.

How do I request prior authorization or limitation extensions? For all requests for prior authorization (PA) or limitation extensions (LE), the following documentation is required: 

A completed, TYPED General Information for Authorization form, 13-835 which MUST be the initial page when you submit your request



A completed Fax/Written Request Basic Information form, 13-756, if there is not a form specific to the service you are requesting, and all the documentation listed on this form and any other medical justification CPT® codes and descriptions only are copyright 2015 American Medical Association

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This documentation should be submitted: 

By Fax Fax prior authorization requests to: 866-668-1214



By Mail Mail prior authorization requests to: Authorization Services Office PO Box 45535 Olympia, WA 98504-5535



Urgent questions or concerns Contact the agency’s Hospice Program Manager: (360) 725-1611

The Medicaid agency will notify the hospice agency when there is an approval or denial for hospice curative treatment. It is the hospice agency's responsibility to continue to coordinate care. 

If the concurrent/curative treatment, related services, or related medications are not covered by the Medicaid agency, the provider must request an exception to rule (ETR) under WAC 182-501-0160. Requests for exception to rule are subject to a medical necessity review under WAC 182-501-0165.



If the Medicaid agency denies a request for a covered service, refer to WAC 182-502-0160 that specifies when a provider or a client may be responsible to pay for a covered service.

Billing When billing for services unrelated to the terminal illness, providers must bill the agency directly. To receive payment: 

The provider must put their NPI in the referring provider field of the HIPAA transaction (field 17 and 17a of the CMS-1500 claim form (version 02/12)).

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Physician-Related Services/Health Care Professional Services 

If not related to hospice care, when billing electronically, enter “Not related to hospice care” in the claim notes field of the HIPAA transaction or field 19 of the CMS-1500 claim form (version 02/12).

When billing services for concurrent/curative care, providers must bill the agency directly with the prior authorization number on the claim.

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Physician-Related Services/Health Care Professional Services

Major Trauma Services Increased payments for major trauma care The legislature established the Trauma Care Fund (TCF) in 1997 to help offset the cost of operating and maintaining a statewide trauma care system. The Department of Health (DOH) and the Health Care Authority (the agency) receive funding from the TCF to help support provider groups involved in the state’s trauma care system. The agency uses its TCF funding to draw federal matching funds. The agency makes supplemental payments to designated trauma centers and pays enhanced rates to physicians/clinical providers for trauma cases that meet specified criteria. The enhanced rates are available for trauma care services provided to a fee-for-service Medical Assistance client with an Injury Severity Score (ISS) of: (a) (b) (c)

13 or greater for adults. 9 or greater for pediatric patients (age 14 and younger). Less than (a) or (b) for a trauma patient received in transfer by a Level I, II, or III trauma center.

Beginning with dates of service on and after July 1, 2012, physicians/clinical providers also receive enhanced rates for qualified trauma care services provided to managed care enrollees who meet trauma program eligibility criteria.

Client eligibility groups included in TCF payments to physicians Claims for trauma care services provided to the following client groups are eligible for enhanced rates:    

Medicaid (Title XIX) CHIP (Title XXI) Medical Care Services (Aged, Blind, and Disabled (ABD) Apple Health for Kids (Children’s Health)

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Client eligibility groups excluded from TCF payments to physicians Claims for trauma care services provided to the following client groups are not eligible for enhanced rates:   

Refugee Assistance Alien Emergency Medical Family Planning Only/TAKE CHARGE

Services excluded from TCF payments to physicians Claims for the following services are not eligible for enhanced rates:    

Laboratory and pathology services Technical Component (TC)-only radiology services Services unrelated to a client’s traumatic injury (e.g., treatment for chronic diseases) Services provided after discharge from the initial hospital stay, except for inpatient rehabilitation services and/or planned follow-up surgery related to the traumatic injury and provided within six months of the date of the traumatic injury

TCF payments to physicians Enhanced rates for trauma care The agency pays a physician an enhanced rate for a qualifying trauma care service, using the lesser of the agency’s maximum allowable fee or the provider’s billed amount as the base rate to which an enhancement percentage is applied. The enhancement percentage is applied at the lineitem level since not all services qualify for an enhanced rate. The agency has a fixed amount to spend on supplemental payments for trauma care. The agency may adjust the enhancement percentage to ensure TCF expenditures do not exceed the amount appropriated to the agency for the state fiscal year. For an eligible trauma service, payment is currently calculated as follows: Trauma care payment = Base rate x 275%

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Criteria for TCF payments to physicians Physicians and clinical providers receive TCF payments from the agency: 1)

For qualified trauma care services. Qualified trauma care services are those that meet the ISS specified in subsection (3) below. Qualified trauma care services also include inpatient rehabilitation and surgical services provided to Medical Assistance clients within six months of the date of the qualifying injury when the following conditions are met: (a)

The follow-up surgical procedures are directly related to the qualifying traumatic injury.

(b)

The follow-up surgical procedures were planned during the initial acute episode of care (inpatient stay).

(c)

The plan for the follow-up surgical procedure(s) is clearly documented in the medical record of the client’s initial hospitalization for the traumatic injury.

2)

For hospital-based services only, except as specified in (4).

3)

Only for trauma cases that meet the ISS of: (a)

Thirteen or greater for an adult trauma patient (a client age 15 or older).

(b)

Nine or greater for a pediatric trauma patient (a client younger than age 15).

(c)

Less than 13 for adults or 9 for pediatric patients for a trauma case received in transfer by a Level I, II, or III trauma service center.

4)

On a claim-specific basis. Services must have been provided in a designated trauma service center, except that qualified follow-up surgical care within six months of the initial traumatic injury, as described in subsection (1) above, may be provided in other approved care settings, such as Medicare-certified ambulatory surgery centers.

5)

At a rate determined by the agency. The enhanced rates are subject to the following limitations: (a)

Laboratory and pathology charges are not eligible for enhanced payments from the TCF. Laboratory and pathology services are paid at the lesser of the agency’s current FFS rate or the billed amount.

(b)

Technical component only (TC) charges for radiology services are not eligible for enhanced rates when billed by physicians. (These are facility charges.) CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services (c)

The rate enhancement percentage is subject to periodic adjustments to ensure that total payments from the TCF for the state fiscal year will not exceed the legislative appropriation for that fiscal year. The agency has the authority to take whatever actions are needed to ensure it stays within its TCF appropriation.

TCF payments to providers in transferred trauma cases When a trauma case is transferred from one hospital to another, the agency makes TCF payments to providers as follows: 

If the transferred case meets or exceeds the appropriate ISS threshold (ISS of 13 or greater for adults, and 9 or greater for pediatric clients), both transferring and receiving hospitals and physicians/clinicians who furnished qualified trauma care services are eligible for increased payments from the TCF. The transfer must be to a higher level designated trauma service center, and the transferring hospital must be at least a level 3 hospital. Transfers from a higher level to a lower level designated trauma service center are not eligible for the increased payments.



If the transferred case is below the ISS threshold, only the receiving hospital and the physicians/clinicians at the receiving facility who furnished qualified trauma care services are eligible for increased payments from the TCF. The transferring hospital and clinical team are paid the regular rates for the services they provided to the transferred client with an ISS below the applicable threshold.

Billing for trauma care services To bill for qualified trauma care services, physicians and clinical providers must add the trauma modifier ST to the appropriate procedure code line. Enter the required ST modifier into the modifier field of the claim to receive the enhanced payment. Note: The ProviderOne system can accommodate up to 4 modifiers on a line, if multiple modifiers are necessary. Claims for trauma care services provided to a managed care enrollee must be submitted to the client’s managed care plan. Claims for trauma care services provided to a fee-for-service client must be submitted to the agency. The payment for a trauma care service provided to a managed care enrollee will be the same amount for the same service provided to a fee-for-service client.

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Adjusting trauma claims The agency considers a provider’s request to adjust a claim for the purpose of receiving TCF payment (e.g., adding the ST modifier to a previously billed service, or adding a new procedure with the ST modifier to the claim) only when the adjustment request is received within one year from the date of service on the initial claim. See WAC 182-502-0150(11). A claim which included a trauma service may be submitted for adjustment beyond 365 calendar days when the reason for the adjustment request is other than TCF payment (e.g., adding lab procedures, correcting units of service). Note: The agency takes back the original payment when processing an adjustment request. Electronic claims get a Julian date stamp on the date received, including weekends and holidays. Paper claims received outside of regular business hours get a Julian date stamp on the following business day. When a trauma care service that was billed timely and received the enhanced rate and is included in a claim submitted for adjustment after 365 days, the agency will pay the provider the regular rate for the service when the adjustment is processed, and recoup the original enhanced payment. All claims and claim adjustments are subject to federal and state audit and review requirements.

Injury severity score (ISS) Note: The current ISS qualifying score is 13 or greater for adults, and 9 or greater for pediatric clients (through age 14 only). The ISS is a summary severity score for anatomic injuries. 

It is based upon the Abbreviated Injury Scale (AIS) severity scores for six body regions:      



Head and neck Face Chest Abdominal and pelvic contents Extremities and pelvic girdle External

The ISS values range from 1 to 75. Generally, a higher ISS indicates more serious injuries.

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Physician-Related Services/Health Care Professional Services

Additional Information For information on the statewide trauma system, designated trauma services, trauma service designation, trauma registry, or trauma care fund (TCF), see the Department of Health’s Trauma System website. For information on payment policy, contact: Office of Hospital Finance Health Care Authority 360-725-1835 For information on a specific trauma claim, contact: Health Care Authority Customer Service Center 800-562-3022

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Physician/clinical provider list Below is a list of providers eligible to receive enhanced rates for providing major trauma care services to Medical Assistance clients: Advanced Registered Nurse Practitioner Anesthesiologist Cardiologist Certified Registered Nurse Anesthetist Critical Care Physician Emergency Physician Family/General Practice Physician Gastroenterologist General Surgeon Gynecologist Hand Surgeon Hematologist Infectious Disease Specialist Internal Medicine Nephrologist Neurologist Neurosurgeon Obstetrician Ophthalmologist Oral/Maxillofacial Surgeon Orthopedic Surgeon Pediatric Surgeon Pediatrician Physiatrist Physician Assistant Plastic Surgeon (not cosmetic surgery) Pulmonologist Radiologist Thoracic Surgeon Urologist Vascular Surgeon Note: Many procedures are not included in the enhanced payment program for major trauma services. The services of some specialists listed above are eligible for enhanced rates only when provided in the context of major trauma care (e.g., stabilization services by a General Practitioner prior to client’s transfer to a trauma care facility; C-Section performed by obstetrician on pregnant accident victim when fetus is in danger). CPT® codes and descriptions only are copyright 2015 American Medical Association

266

Physician-Related Services/Health Care Professional Services

Oral Health Access to Baby and Child Dentistry (ABCD) Program What is the purpose of the ABCD program? The purpose of the ABCD program is to increase access to preventive dental services for infants, toddlers, and preschoolers age five and younger who are eligible for Washington Apple Health (Medicaid). To find out more about the ABCD program, visit Access to Baby & Child Dentistry.

What dental services are billable by primary care medical providers? The agency pays primary care medical providers (physicians, ARNPs, and PAs) for delivering periodic oral evaluations, topical application of fluoride, and family oral health education as follows: Payment CDT Code

ICD Diagnosis Code

D0120

Z00.129

Periodic oral evaluation

$29.46

D1206

Z00.129

Topical application of fluoride varnish

$13.25

D1208

Z00.129

Topical application of fluoride

$13.25

D9999

Z00.129

Family oral health education

$27.58

Description

Maximum Allowable Fee

Limitations *One periodic oral evaluation is allowed every six months through age 5 per provider, per client **Up to 3 times in a 12-month period through age 6, per provider, per client; 2 times in a 12-month period for ages 7-18, per provider, per client. **Up to 3 times in a 12-month period through age 6, per provider, per client; 2 times in a 12-month period for ages 7-18, per provider, per client. *One visit per day per family, per provider. Up to 2 visits in a 12-month period through age 5 per provider, per client.

* The agency pays only certified providers for these services. See Training and Certification for more information on how to become certified.

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Physician-Related Services/Health Care Professional Services ** D1206 and D1208 are not allowed on the same day. The fluoride limit per provider, per client for D1206 and D1208 is the combined total of the two; not per code. The codes are considered equivalent and a total of 3 or 2 fluorides are allowed, not 3 or 2 of each.

Training and certification To become trained and certified to provide the services in the table above, primary care medical providers must complete a class offered by Washington Dental Service Foundation (WDSF). The 1 ½ hour continuing medical education (CME) class is given in-office or in community settings and teaches providers to deliver the following preventive services:

     

Links between oral health and total health Oral health screening and risk assessment Providing oral health education and anticipatory guidance to clients and families Application of topical fluoride Billing Referrals for dental care

Contact WDSF at [email protected] or 206-473-9542 for questions about current certification or for scheduling certification training.

Dental disease prevention services The agency pays enhanced fees to certified participating primary care medical providers for delivering the following services: 

Periodic oral evaluations.



Topical application of fluoride (fluoride varnish).



Family oral health education. An oral health education visit must include all of the following, when appropriate: 

"Lift Lip" training: Show the parent(s)/guardian(s) how to examine the child using the lap position. Ask if the parent(s)/guardian(s) feel comfortable doing this once per month.



Oral hygiene training: Demonstrate how to position the child to clean the teeth. Record that this was demonstrated.



Risk assessment for early childhood caries: Assess the risk of dental disease for the child. Obtain a history of previous dental disease activity for this child and any siblings from the parent(s)/guardian(s). Also note the dental health of the parent(s)/guardian(s). CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services 

Dietary counseling: Talk with the parent(s)/guardian(s) about the need to use a cup, rather than a bottle, when giving the child anything sweet to drink. Note that dietary counseling delivered.



Discussion of fluoride supplements: Discuss fluoride supplements with the parent(s)/guardian(s). Let the parent/guardian know fluoride supplements are covered under the agency's Prescription Drug program. Fluoride prescriptions written by the primary care medical provider may be filled at any Medicaidparticipating pharmacy. Ensure that the child is not already receiving fluoride supplements.



Documentation: in the client’s file or the client’s designated adult member’s (family member or other responsible adult) file to record the activities provided.

Oral Surgery Services performed by a physician or dentist specializing in oral maxillofacial surgery (WAC 182-535-1094)

Provider requirements 

An appropriate consent form, if required, signed and dated by the client or the client’s legal representative must be in the client’s record.



An anesthesiologist providing oral health care under this section must have a current provider’s permit on file with the agency.



A health care provider providing oral or parenteral conscious sedation, or general anesthesia, must meet all of the following:   



The provider’s professional organization guidelines The Department of Health (DOH) requirements in chapter 246-817 WAC Any applicable DOH medical, dental, and nursing anesthesia regulations

Agency-enrolled dental providers who are not specialized to perform oral and maxillofacial surgery must use only the current dental terminology (CDT) codes to bill claims for services that are listed in the Coverage Table. (See WAC 182-535-1070(3))

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Oral surgery coverage table The agency covers the following services: Procedure Code 10060 10120 10140 11000 11012 11042 11044 11100 11101 11440 11441 11442 11443 11444 11446 11640 11641 11642 11643 11644 11646 12001 12002 12004 12005 12011 12013 12014 12015 12016 12031 12032 12034 12035 12036 12051 12052

PA? N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Short Description Drainage of skin abscess Remove foreign body Drainage of hematoma/fluid Debride infected skin Deb skin bone at fx site Deb subq tissue 20 sq cm/< Deb bone 20 sq cm/< Biopsy, skin lesion Biopsy, skin add-on Exc face-mm b9+marg 0.5 < cm Exc face-mm b9+marg 0.6-1 cm Exc face-mm b9+marg 1.1-2 cm Exc face-mm b9+marg 2.1-3 cm Exc face-mm b9+marg 3.1-4 cm Exc face-mm b9+marg > 4 cm Exc face-mm malig+marg 0.5 < Exc face-mm malig+marg 0.6-1 Exc face-mm malig+marg 1.1-2 Exc face-mm malig+marg 2.1-3 Exc face-mm malig+marg 3.1-4 Exc face-mm mlg+marg > 4 cm Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Intmd wnd repair s/tr/ext Intmd wnd repair s/tr/ext Intmd wnd repair s/tr/ext Intmd wnd repair s/tr/ext Intmd wnd repair s/tr/ext Intmd wnd repair face/mm Intmd wnd repair face/mm

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Physician-Related Services/Health Care Professional Services Procedure Code 12053 12054 12055 12056 13121 13122 13131 13132 13133 13151 13152 13153 13160 14040 15120 15275 15278 15576 15732 17110 20220 20520 20552 20605 20615 20670 20680 20690 20692 20902 20926 20955 20969 20970 21010 21013 21015 21016 21025 21026 21029 21030 21034

PA? N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Short Description Intmd wnd repair face/mm Intmd wnd repair, face/mm Intmd wnd repair face/mm Intmd rpr face/mm 20.1-30.0 Cmplx rpr s/a/l 2.6-7.5 cm Cmplx rpr s/a/l addl 5 cm/> Repair of wound or lesion Repair of wound or lesion Repair wound/lesion add-on Repair of wound or lesion Repair of wound or lesion Repair wound/lesion add-on Late closure of wound Skin tissue rearrangement Skn splt a-grft fac/nck/hf/g Skin sub graft face/nk/hf/g Skn sub grft f/n/hf/g ch add Form skin pedicle flap Muscle-skin graft head/neck Destruct b9 lesion 1-14 Bone biopsy, trocar/needle Removal of foreign body Inj trigger point 1/2 muscl Drain/inject, joint/bursa Treatment of bone cyst Removal of support implant Removal of support implant Apply bone fixation device Apply bone fixation device Removal of bone for graft Removal of tissue for graft Fibula bone graft, microvasc Bone/skin graft, microvasc Bone/skin graft, iliac crest Incision of jaw joint Exc face tum deep < 2 cm Resect face tum < 2 cm Resect face tum 2 cm/> Excision of bone, lower jaw Excision of facial bone(s) Contour of face bone lesion Excise max/zygoma b9 tumor Excise max/zygoma mlg tumor

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Physician-Related Services/Health Care Professional Services Procedure Code 21040 21044 21045 21046 21047 21048 21049 21050 21060 21070 21073 21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100 21110 21116 21120 21121 21122 21123 21141 21142 21143 21145 21146 21147 21150 21151 21154 21155 21159 21160

PA? N N Y N N N N Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Short Description Excise mandible lesion Removal of jaw bone lesion Extensive jaw surgery Remove mandible cyst complex Excise lwr jaw cyst w/repair Remove maxilla cyst complex Excis uppr jaw cyst w/repair Removal of jaw joint Remove jaw joint cartilage Remove coronoid process Mnpj of tmj w/anesth Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Maxillofacial fixation Interdental fixation Injection, jaw joint x-ray Reconstruction of chin Reconstruction of chin Reconstruction of chin Reconstruction of chin Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort Reconstruct midface, lefort

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272

Physician-Related Services/Health Care Professional Services Procedure Code 21193 21194 21195 21196 21198 21206 21208 21209 21210 21215 21230 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21295 21296 21315 21320 21330 21337 21338 21343 21344 21345 21346 21347 21348 21355 21356 21360 21365 21366 21386 21387 21390 21406

PA? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N N

Short Description Reconst lwr jaw w/o graft Reconst lwr jaw w/graft Reconst lwr jaw w/o fixation Reconst lwr jaw w/fixation Reconstr lwr jaw segment Reconstruct upper jaw bone Augmentation of facial bones Reduction of facial bones Face bone graft Lower jaw bone graft Rib cartilage graft Reconstruction of jaw joint Reconstruction of jaw joint Reconstruction of jaw joint Reconstruction of lower jaw Reconstruction of jaw Reconstruction of jaw Reconstruct lower jaw bone Reconstruction of jaw Reconstruction of jaw Reconstruct lower jaw bone Revision of jaw muscle/bone Revision of jaw muscle/bone Closed tx nose fx w/o stablj Closed tx nose fx w/ stablj Open tx nose fx w/skele fixj Closed tx septal&nose fx Open nasoethmoid fx w/o fixj Open tx dprsd front sinus fx Open tx compl front sinus fx Treat nose/jaw fracture Treat nose/jaw fracture Treat nose/jaw fracture Treat nose/jaw fracture Treat cheek bone fracture Treat cheek bone fracture Treat cheek bone fracture Treat cheek bone fracture Treat cheek bone fracture Opn tx orbit fx periorbital Opn tx orbit fx combined Opn tx orbit periorbtl implt Opn tx orbit fx w/o implant

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273

Physician-Related Services/Health Care Professional Services Procedure Code 21407 21421 21422 21423 21431 21432 21433 21435 21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490 21495 21497 21550 21555 29800 29804 30580 30600 31000 31030 31032 31225 31502 31515 31525 31530 31600 31603 31830 38510

PA? N N N N N N N N N N N N N N N N N N N N N N N N N N Y Y Y N N N N N N N N N N N N Y N

Short Description Opn tx orbit fx w/implant Treat mouth roof fracture Treat mouth roof fracture Treat mouth roof fracture Treat craniofacial fracture Treat craniofacial fracture Treat craniofacial fracture Treat craniofacial fracture Treat craniofacial fracture Treat dental ridge fracture Treat dental ridge fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Reset dislocated jaw Reset dislocated jaw Repair dislocated jaw Treat hyoid bone fracture Interdental wiring Biopsy of neck/chest Exc neck les sc < 3 cm Jaw arthroscopy/surgery Jaw arthroscopy/surgery Repair upper jaw fistula Repair mouth/nose fistula Irrigation, maxillary sinus Exploration, maxillary sinus Explore sinus remove polyps Removal of upper jaw Change of windpipe airway Laryngoscopy for aspiration Dx laryngoscopy excl nb Laryngoscopy w/fb removal Incision of windpipe Incision of windpipe Revise windpipe scar Biopsy/removal lymph nodes

CPT® codes and descriptions only are copyright 2015 American Medical Association

274

Physician-Related Services/Health Care Professional Services Procedure Code 38700 38724 40490 40510 40700 40701 40702 40720 40800 40801 40804 40805 40806 40808 40810 40812 40814 40816 40819 40830 40831 40840 40842 40845 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018 41100 41105 41108 41110 41112 41113 41114 41115

PA? N N N N N N N Y N N N N N N N N N N N N N N N Y N N N N N N N N N N N N N N N N N N N

Short Description Removal of lymph nodes neck Removal of lymph nodes neck Biopsy of lip Partial excision of lip Repair cleft lip/nasal Repair cleft lip/nasal Repair cleft lip/nasal Repair cleft lip/nasal Drainage of mouth lesion Drainage of mouth lesion Removal, foreign body, mouth Removal, foreign body, mouth Incision of lip fold Biopsy of mouth lesion Excision of mouth lesion Excise/repair mouth lesion Excise/repair mouth lesion Excision of mouth lesion Excise lip or cheek fold Repair mouth laceration Repair mouth laceration Reconstruction of mouth Reconstruction of mouth Reconstruction of mouth Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Incision of tongue fold Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Biopsy of tongue Biopsy of tongue Biopsy of floor of mouth Excision of tongue lesion Excision of tongue lesion Excision of tongue lesion Excision of tongue lesion Excision tongue fold

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275

Physician-Related Services/Health Care Professional Services Procedure Code 41116 41120 41130 41135 41520 41530 41599 41800 41805 41821 41822 41823 41825 41826 41827 41828 41830 41850 41899 42100 42104 42106 42180 42182 42200 42205 42210 42215 42220 42225 42226 42227 42235 42260 42280 42281 42330 42335 42405 42408 42409 42440 42450

PA? N N Y N N Y N N N N N N N N N N N N Y N N N Y Y N N N N N N Y Y Y N N N N N N N N N N

Short Description Excision of mouth lesion Partial removal of tongue Partial removal of tongue Tongue and neck surgery Reconstruction tongue fold Tongue base vol reduction Tongue and mouth surgery Drainage of gum lesion Removal foreign body, gum Excision of gum flap Excision of gum lesion Excision of gum lesion Excision of gum lesion Excision of gum lesion Excision of gum lesion Excision of gum lesion Removal of gum tissue Treatment of gum lesion Dental surgery procedure Biopsy roof of mouth Excision lesion, mouth roof Excision lesion, mouth roof Repair palate Repair palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Lengthening of palate Lengthening of palate Repair palate Repair nose to lip fistula Preparation, palate mold Insertion, palate prosthesis Removal of salivary stone Removal of salivary stone Biopsy of salivary gland Excision of salivary cyst Drainage of salivary cyst Excise submaxillary gland Excise sublingual gland

CPT® codes and descriptions only are copyright 2015 American Medical Association

276

Physician-Related Services/Health Care Professional Services Procedure Code 42500 42505 42600 42700 42720 42725 43200 64400 64600 64774 64784 64788 64790 64792 64795 64864 64910 70300 70310 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99231 99232 99233 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255

PA? N N N N N N N N Y N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Short Description Repair salivary duct Repair salivary duct Closure of salivary fistula Drainage of tonsil abscess Drainage of throat abscess Drainage of throat abscess Esophagus endoscopy N block inj trigeminal Injection treatment of nerve Remove skin nerve lesion Remove nerve lesion Remove skin nerve lesion Removal of nerve lesion Removal of nerve lesion Biopsy of nerve Repair facial nerve Nerve repair w/allograft X-ray exam of teeth X-ray exam of teeth Office/outpatient visit, new* Office/outpatient visit, new* Office/outpatient visit new* Office/outpatient visit new* Office/outpatient visit new* Office/outpatient visit, est* Office/outpatient visit est* Office/outpatient visit est* Office/outpatient visit est* Office/outpatient visit est* Subsequent hospital care* Subsequent hospital care* Subsequent hospital care* Office consultation* Office consultation* Office consultation* Office consultation* Office consultation* Inpatient consultation* Inpatient consultation* Inpatient consultation* Inpatient consultation* Inpatient consultation*

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Physician-Related Services/Health Care Professional Services

*Billing evaluation and management (E/M) codes Dentists specializing in oral surgery must use CPT codes and follow CPT rules when billing for evaluation and management of clients. When billing for these services, the following must be true:  

Services must be billed on an 837P HIPAA compliant claim form. Services must be billed using one of the CPT codes above and modifiers must be used if appropriate.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Prosthetic/Orthotics Prosthetic & orthotics for podiatry and orthopedic surgeons The following codes are payable only to podiatrists and orthopedic surgeons: HCPCS Short Description Policy Comments Code A5500 Diab shoe for density insert Limit 1 per client, per year A5501 Diabetic custom molded shoe Limit 1 per client, per year A5503 Diabetic shoe w/roller/rocker Limit 1 per client, per year A5504 Diabetic shoe with wedge Limit 1 per client, per year A5505 Diab shoe w/metatarsal bar Limit 1 per client, per year A5506 Diabetic shoe w/offset heal Limit 1 per client, per year A5507 Modification diabetic shoe Requires PA A5512 Multi den insert direct form Limit 1 per client, per year A5513 Multi den insert custom mold Limit 1 per client, per year L1902 Afo ankle gauntlet L1906 Afo multiligamentus ankle su L3000 Ft insert ucb berkeley shell EPA required EPA required L3030 Foot arch support remov prem L3140 Abduction rotation bar shoe L3150 Abduct rotation bar w/o shoe PA required L3170 Foot plastic heel stabilizer L3215 Orthopedic ftwear ladies oxf EPA required. Noncovered for clients age 21 and older L3219 Orthopedic mens shoes oxford EPA required. Noncovered for clients age 21 and older L3310 Shoe lift elev heel/sole neo Limit 1 per client, per year L3320 Shoe lift elev heel/sole cor Limit 1 per client, per year L3334 Shoe lifts elevation heel /i Limit 1 per client, per year L3340 Shoe wedge sach PA required L3350 Shoe heel wedge PA required L3360 Shoe sole wedge outside sole PA required L3400 Shoe metatarsal bar wedge ro PA required L3410 Shoe metatarsal bar between PA required L3420 Full sole/heel wedge between PA required L3430 Shoe heel count plast reinfor Limit 1 per client, per year L4350 Ankle control orthosi prefab Fractures only L4360 Pneumatic walking boot prefab Fractures only; PA required L4380 Pneumatic knee splint L4386 Non-pneum walk boot prefab PA required (For authorization requirements, follow the Prosthetic and Orthotic Devices Provider Guide.)

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Physician-Related Services/Health Care Professional Services

Supplies paid separately when dispensed from provider’s office/clinic Casting materials Bill the appropriate HCPCS code (Q4001-Q4051) for fiberglass and plaster casting materials limited to one unit per limb per day. Do not bill for the use of a cast room. Use of a cast room is considered part of a provider's practice expense.

Inhalation solutions Refer to the Injectable Drugs Fee Schedule for those specific codes for inhalation solutions that are paid separately.

Metered dose inhalers and accessories HCPCS Code A4614 A4627

Short Description Hand-held PEFR meter Spacer bag/reservoir

Miscellaneous prosthetics & orthotics HCPCS Code L0120 L0220 L1810 L1820 L1830 L3650 L3807

Short Description Cerv flexible non-adjustable Thor rib belt custom fabrica Ko elastic with joints Ko elas w/ condyle pads & jo Ko immobilizer canvas longit Shlder fig 8 abduct restrain WHFO,no joint, prefabricated

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Physician-Related Services/Health Care Professional Services HCPCS Code L3908 L8000 L8010 L8600

Short Description Wrist cock-up non-molded Mastectomy bra Mastectomy sleeve Implant breast silicone/eq

For additional information and authorization requirements, see the agency’s Prosthetic & Orthotic Devices Provider Guide.

Miscellaneous Supplies HCPCS Code A4561 A4562 A4565 A4570 L8695

Short Description Pessary rubber, any type Pessary, nonrubber, any type Slings Splint External recharge sys extern. (Requires PA)

Radiopharmaceutical diagnostic imaging agents Refer to the Injectable Drugs Fee Schedule for those specific codes for imaging agents that are paid separately.

Urinary tract implants See important policy limitations in Surgery - Urinary Systems. HCPCS Code L8603 L8604 L8606

Short Description Collagen imp urinary 2.5 ml Dextranomer/hyaluronic acid Synthetic implnt urinary 1ml

Note: L8603, L8604 and/or L8606 must be billed on the facility claim only if the implantation procedure is performed in place of service 21 and 22.

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Physician-Related Services/Health Care Professional Services

Transgender Health Services For resources that may be helpful for providing healthcare services to members of the transgender community, go to www.hca.wa.gov/medicaid/transhealth .

What transgender health services are covered? (WAC 182-531-1675) In addition to all the other services addressed in this provider guide, Medicaid covers the following service related to transgender health and the treatment of gender dysphoria:           

Hormone replacement therapy (HRT) Pre-puberty suppression therapy Mental health Surgical services Anesthesiology Labs Pathology Radiology Hospitalization Physician services Hospitalizations and physician services related to postoperative complications of procedures performed for gender reassignment surgery

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Physician-Related Services/Health Care Professional Services

Fee-for-service clients All the services listed in “What transgender health services are covered?” are covered for clients who are enrolled under Medicaid’s fee-for-service program. Some services require prior authorization (PA). See What is prior authorization (PA)?

Managed care clients Services covered under a managed care organization (MCO): If the client is covered under an agency-contracted MCO, the MCO is responsible for all medical care including hormone and mental health services to treat gender dysphoria. Contact the MCO for requirements for those services. Some clients may meet the access to care standards, therefore these mental health care services may be provided by a community mental health agency under the Behavioral Health Organization (BHO). (See Chapter 388-865 WAC) Services covered under fee-for-service:



If the client is covered under an MCO, fee-for-service is responsible for surgical procedures, including electrolysis and post-operative complications if required, to treat gender dysphoria. These services require PA by the Medicaid agency. See What is prior authorization (PA)?



The agency pays for surgical procedures related to gender reassignment surgery (GRS) and electrolysis and postoperative complications through fee-for-service (FFS). The MCO is not responsible for surgical procedures related to GRS, including electrolysis and postoperative complications. PA is required from the agency for these procedures. When billing the agency for complications related to GRS, providers must add “post-GRS surgery” in the Comments field on the claim form.

What are the components of transgender health services? The gender dysphoria treatment program has four components. Prior authorization (PA) is required for component four only (surgical). The MCO’s case managers and the FFS staff coordinate care across the programs. The components described below are not intended to be sequential and may run concurrently to meet the client’s medical needs.

Component 1 – Includes the following:  

Conducting an initial assessment and makes or confirms the diagnosis Developing an individualized treatment plan CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services  

Managing referrals to other qualified providers as indicated and Assisting with navigation of other program requirements

Component one must be provided by a Center-of-Excellence (COE) provider who is a boardcertified physician, a psychologist, a board-certified psychiatrist, or a licensed advanced registered nurse practitioner (ARNP). Component one services provided should be consistent with World Professional Association for Transgender Health (WPATH) Standards of Care and WAC 182-531-1675.

Component 2 – Includes mental health and medical services directly related to the pathway to gender reassignment surgery. 

Medical treatment may include androgen suppression, puberty suppression, continuous hormone therapy, and laboratory testing to monitor the safety of hormone therapy. Providers must list a gender dysphoria (F64.1 and F64.2) diagnosis on prescriptions for their clients receiving hormone replacement or puberty blocking agents.



Mental health treatment, provided to the client, client’s spouse, parent, guardian, child, or person with whom the client has a child in common, if the treatment is directly related to the client’s care, is medically necessary and is in accordance with the provisions of WAC 182-531-1400.

These services must be provided by agency-approved COE providers. Component 3 – Includes pre-surgical requirements as follows: 

For top surgery: A referral to the surgeon from a PCP and a comprehensive evaluation by an agency-approved COE mental health professional.



For bottom surgery: A referral to the surgeon from a PCP, a comprehensive evaluation by two agency approved COE mental health professionals and a pre-surgical consultation by an agency-approved COE surgeon.

Component 4 - Includes surgical interventions and requirements. Prior authorization is required for this component only (surgical). 

Client requirements - The client must:   

Be age 18 or older, unless allowed under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program Be competent to give consent for treatment and undergo a comprehensive psychosocial evaluation Have received continuous hormonal therapy as required by the treatment plan to meet treatment objectives CPT® codes and descriptions only are copyright 2015 American Medical Association

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Have lived in a gender role congruent with the client's gender identity immediately preceding surgery as required by the treatment plan to meet treatment objectives Note for EPSDT: If gender dysphoria treatment is requested or prescribed for clients age 20 and younger under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, the agency evaluates it as a covered service under the EPSDT program’s requirement that the service is medically necessary, safe, effective, and not experimental.



Prior authorization (PA) – PA is required for Component 4 only. Providers must fax a completed General Authorization form (HCA 13-835) along with any additional documentation required below to the agency at (360) 866-668-1214: For top surgery The agency requires referral letters from each of the following:  One mental health provider which addresses all of the following:  Confirm the diagnosis of gender dysphoria using current DSM 5 (Diagnostic and Statistical Manual of Mental Disorders) criteria  Assure the client is a good candidate  Assure the surgery is the next reasonable step in the care  Assure the client has no coexisting behavioral health conditions (substance abuse problems, or mental health illnesses), which could hinder participation in gender dysphoria treatment  Assure any coexisting behavioral health condition is adequately managed  The provider managing the hormonal therapy:  Outcome of clients current hormonal therapy  The surgeon performing surgery:  Written surgical consultation For bottom surgery The agency requires referral letters from each of the following:  Two mental health providers which addresses all of the following:  The psychosocial evaluation  Confirm the diagnosis of gender dysphoria using current DSM 5 (Diagnostic and Statistical Manual of Mental Disorders) criteria  Assure the client is a good candidate CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services  Assure the surgery is the next reasonable step in the care  Assure the client has no coexisting behavioral health conditions (substance abuse problems, or mental health illnesses), which could hinder participation in gender dysphoria treatment  Assure any coexisting behavioral health condition is adequately manage  Description of the relationship between the mental health professional and the client and treatment to date  The surgeon performing surgery:     

Written surgical consultation Clinical justification for surgery Confirmation that the client is able to comply with the postoperative requirements Assurance that all surgical criteria has been met or medical necessity is established Copy of the signed Sterilization Consent form (HCA 13-364) with the clients understanding of the permanent impact on the reproductive system consistent with the requirements of WAC 182-531-1550  The surgical plan description with listed all planned procedures and timeline Surgeons must indicate in Comments field 30 on the agency’s General Authorization form (HCA 13-835) the suite of services being requested according to their Core Provider Agreement contract addendum. 

The provider managing the hormonal therapy:  A statement regarding the client’s adherence to the medical and mental treatment plan  Outcome of client’s current hormonal therapy  Assurance that all the members of the treatment team will be available to coordinate or provide postoperative care as needed

Note: If the client fails to complete all of the requirements above, the agency will require documentation of the clinical decision-making process in the prior authorization submission in order to review for individual consideration. 

Covered services – The agency covers the following services in Component 4:       

Blepharoplasty Breast reconstruction (male to female) Cliteroplasty Colovaginoplasty Colpectomy Genital surgery Genital electrolysis as required as part of the genital surgery CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services                 

Hysterectomy Labiaplasty Laryngoplasty Mammoplasty with or without chest reconstruction Metoidioplasty Orchiectomy Panniculectomy Penectomy Phalloplasty Placement of testicular prosthesis Rhinoplasty Salpingo-oophorectomy Scrotoplasty Urethroplasty Vaginectomy Vaginoplasty

Noncovered services – For purposes of this section, the agency will review on a case-bycase basis and may pay for the following noncovered services under exception to rule:  Cosmetic procedures and services:                     

Brow lift Calf implants Cheek/malar implants Chin/nose implants Collagen injections Drugs for hair loss or growth Facial or trunk electrolysis, except for the limited electrolysis Facial feminization Face lift Forehead lift Hair transplantation Jaw shortening Lip reduction Liposuction Mastopexy Neck tightening Pectoral implants Reduction thyroid chondroplasty Removal of redundant skin Suction-assisted lipoplasty of the waist Trachea shave

 Voice modification surgery CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services  Voice therapy Note: Requests for any noncovered service listed above are reviewed as an exception to rule under the provisions of WAC 182-501-0160. The justification included in the surgical plan for any of the procedures listed may be recognized by the agency as meeting the documentation requirements of WAC 182-501-0160.

Who can provide gender dysphoria-related treatment? Providers must meet the qualifications outlined in chapter 182-502 WAC. Providers must be recognized as an agency-designated center of excellence (COE). COE is defined in WAC 182531-0050. In order to be a COE, all providers must complete the applicable agency attestation form (see Where can I download the attestation form?) stating they have met the following: 

Possess knowledge about current community, advocacy, and public policy issues relevant to transgender people and their families (sexuality, sexual health concerns, and the assessment and treatment of sexual disorders is preferred)



Endorse the Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People, Version 7 as developed by the World Professional Association for Transgender Health (WPATH)



Agree to provide services consistent with WAC 182-531-1675

Where can I download the attestation form? The following attestation forms are located on the agency’s Medicaid Forms page:   

Attestation for Surgeons Performing Gender Reassignment Surgery (HCA 18-492) Attestation for Mental Health Providers Treating Transgender Patients (HCA 18-493) Attestation for Medical Providers Treating Transgender Patients (HCA 18-494)

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How do I become a COE provider? If you are seeing transgender clients or would like to, please contact the agency in one of the following ways: Send an email to the [email protected] requesting information Access the agency’s Transhealth website at: www.hca.wa.gov/medicaid/transhealth for instructions on how to become a COE for this program

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Medical Necessity Review by Qualis Health What is a medical necessity review by Qualis Health? The agency contracts with Qualis Health to provide web-based access for reviewing medical necessity for:    

Outpatient advanced imaging services Select surgical procedures Outpatient advanced imaging Spinal injections, including diagnostic selective nerve root blocks

Qualis Health conducts the review of the request to establish medical necessity, but does not issue authorizations. Qualis Health forwards its recommendations to the agency for final authorization determination. The procedure codes that require review by Qualis Health can be found in the agency’s Physician-Related/Professional Health Care Services fee schedule. Note: This process through Qualis Health is for Washington Apple Health (Medicaid) clients enrolled in fee-for-service only. Authorization requests for managed care clients will not be authorized.

Who can request a review? Only the performing provider or facility (site of service) can request the medical necessity review by Qualis Health. If initiating the request for authorization, the physician must include the name and billing NPI of the facility where the procedure will be performed. If a facility is requesting the authorization, the request must include the name and billing NPI of the physician performing the procedure. Note: Billing entities such as clearinghouses do not request authorization through Qualis Health or the agency.

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How do I register with Qualis Health? In order to submit requests to Qualis Health, providers must:   

Register as a provider through www.qualishealth.org. Register as a Washington State Medicaid provider. Be familiar with the criteria that will be applied to requests.

Qualis offers on-line training and a printable WA Medicaid Training Manuals. Note: A username and password is needed for Washington State Medicaid even if a provider is already a registered provider with Washington State Labor and Industries.

Is authorization required for all Washington Apple Health (Medicaid) clients? No. Authorization through Qualis Health is required only for Washington Apple Health clients who are currently eligible and enrolled in fee-for-service as the primary insurance and Emergency Related Services Only (ERSO) noncitizen program/Alien Medical Program (AMP) clients.

DO NOT submit a request for a client who has:      

Medicaid Managed Care. Another insurance as primary (Third Party Liability or TPL). Medicare as the primary insurance. No current eligibility. Unmet spenddown. Detoxification only coverage.

If one of the above applies, the agency will reject the request for authorization regardless of Qualis Health's medical necessity determination. For ERSO/AMP clients in the cancer or end stage renal disease (ESRD) program (WAC 182-507-0120), submit all imaging and surgical requests to Qualis Health.

Reminder: Check client eligibility before submitting a request! An agency Washington Apple Health (Medicaid) eligibility ID card does not guarantee that a client is currently eligible. To save time, confirm eligibility through ProviderOne before submitting an authorization request. To learn more about confirming client eligibility in ProviderOne, go to the ProviderOne Billing and Resource Guide. CPT® codes and descriptions only are copyright 2015 American Medical Association

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How do I submit a request to Qualis Health? Requests may be submitted electronically, by fax, or via telephone. Instructions for submitting a medical necessity review request, including how to use OneHealthPort, are available at Qualis Health.

Fax or Telephone Option Through Qualis Health Fax and telephone requests are available only to providers who do not have access to a computer. Requests initiated by telephone or fax will require supporting documentation to be faxed per the instructions found at Qualis Health. Once supporting documentation is received, Qualis Health will open a case in their system by:  

Entering the information. Responding to the provider with a Qualis Health reference number.

Once all necessary clinical information is received (either electronically or via fax), Qualis Health staff will:  

Conduct the medical necessity review. Forward a recommendation to the agency.

Qualis Health will process telephone and fax requests during normal business hours. Faxed requests can be sent at any time and Qualis Health will process them the following business day. Qualis Health provides the following toll-free numbers:  

Washington Apple Health (Medicaid) (phone) 888-213-7513 Washington Apple Health (Medicaid) (fax) 888-213-7516

What is the Qualis Health reference number for? Upon successful submission of a request through iEXCHANGE® or when a request has been faxed to Qualis Health, a provider will receive a 9-digit Qualis Health reference number starting with the prefix 913 (e.g. 913-xxx-xxx). The Qualis Health reference number provides verification that Qualis Health reviewed the request. A Qualis Health reference number is NOT a billable authorization number. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Providers must not bill for or perform a procedure(s) until a written approval and an agencyissued ProviderOne authorization number is received. The agency approves or denies authorization requests based on recommendations from Qualis Health. For questions regarding the status of an authorization, need to update an authorization, or have general questions regarding an authorization, contact the agency at 1-800-562-3022, ext. 52018. Note: The agency has 15 calendar days from the time Qualis Health receives a request for authorization to provide a written determination.

When does the agency consider retroactive authorizations? The agency considers retroactive authorization when one of the following applies: 

The client’s eligibility is verifiably approved after the date of service, but retroactive to a date(s) that includes the date that the procedure was performed.



The primary payer does not pay for the service and payment from Medicaid is being identified as the primary payer. Note: Retroactive authorizations must be submitted to Qualis Health within 5 business days for procedures or advanced imaging performed as urgent or emergency procedures on the same day.

When requesting retroactive authorization for a required procedure, providers must check authorization requirements for the date of service that the procedure was performed.

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What are the authorization requirements for advanced imaging? For advanced imaging, providers must complete the appropriate questionnaire form. Questionnaires for radiology services are available online from Qualis Health and can be printed out for provider convenience. Some radiology codes continue to require prior authorization (PA) from the agency, but not from Qualis Health. See the Physician-Related/Professional Services Fee Schedule. Note: The PA requirement is for diagnostics provided as urgent and scheduled. The agency allows 5 business days to complete authorization for urgent or ordered-the-same-day procedures when the authorization cannot be completed before the procedure is performed. This authorization requirement does not apply to diagnostics done in association with an emergency room visit, an inpatient hospital setting, or when another payer, including Medicare, is the primary payer.

How does the agency’s hierarchy of evidence protocol apply? The criteria in the online Qualis Health questionnaires represent “B” level of evidence under WAC 182-501-0165. In other words, this represents the clinical/treatment guideline* the agency has adopted to establish medical necessity and make authorization decisions for these advanced imaging procedures. “B” level evidence shows the requested service or equipment has some proven benefit supported by: 

Multiple Type II or III evidence or combinations of Type II, III or IV evidence with generally consistent findings of effectiveness and safety (A "B" rating cannot be based on Type IV evidence alone).



Singular Type II, III, or IV evidence in combination with agency-recognized:   

Clinical guidelines*. Treatment pathways*. Other guidelines that use the hierarchy of evidence in establishing the rationale for existing standards.

If the criteria in the questionnaire are not met, the request will be denied. *Note: In most circumstances, the agency’s program uses the same criteria and questionnaires as Labor and Industries for MRIs and CT scans. CPT® codes and descriptions only are copyright 2015 American Medical Association

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What are the authorization requirements for surgical procedures? Requests initiated electronically will require supporting documentation to be included with the electronic submission or faxed per the instructions found at Qualis Health. Surgical services require agency authorization regardless of place of service or when performed as:   

Urgent. An emergency. A scheduled surgery.

If the client is age 20 and younger, prior authorization for the surgical procedure may not be required. See the agency’s Physician-Related/Professional Services Fee Schedule to determine if a procedure is exempt by client's age.

Surgical Modifiers Co-Surgeons, Assistants, Team Surgeries, and other surgical modifiers When requesting an authorization for any surgical procedure requiring a medical necessity review by Qualis Health, indicate if the authorization request also includes an assistant surgeon, a co-surgeon, or a surgical team. For further information, see the Centers for Medicare and Medicaid’s (CMS) Global Surgery Fact Sheet or CMS’s Claims Processing Manual for Physicians/Nonphysician Practitioners. When submitting an authorization request for a surgical service that requires additional surgeons, include the following on the request:   

The appropriate modifier(s) If available, each surgeon’s billing NPI Clinical justification for an assistant surgeon, co-surgeon, or surgical team

Enter the information above in the Communication box when:  

The case is loaded through Qualis Health iEXCHANGE®. OR Submitted by fax, on the Request for Surgical Authorization form.

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How does the agency’s hierarchy of evidence protocol apply? Hierarchy of Evidence (See WAC 182-501-0165) The agency recognizes the criteria described as “B” level of evidence. If the request meets medical necessity criteria, the request will be approved.

What criteria will Qualis Health use to establish medical necessity? The agency has instructed Qualis Health to use the following surgical procedure criteria to establish medical necessity:   

Health Technology Assessment (HTA) Program* Labor and Industries ( LNI) InterQual criteria

Exceptions: *Washington Apple Health (Medicaid) does not require clients to participate in a structured, intensive, multi-disciplinary program (SIMP) as required in the HTA's decision for spinal fusion and artificial disc replacement surgery. If there is an applicable HTA criterion, the criterion will serve as the benchmark for the medical necessity review. If there are no HTA criteria available, applicable criteria from Washington State’s Labor & Industries (L&I) Medical Treatment Guidelines (MTG) will be applied. If L&I does not have available criteria, InterQual criteria will be applied.

Is there a provider appeals process for Qualis Health? Yes. If the agency denies authorization as a result of a recommendation from Qualis Health, Qualis Health offers providers an appeal process. Request an appeal as follows: 

Prepare a written request for appeal to Qualis Health indicating the Qualis Health reference number (starting with 913…) for which the appeal is requested.



Fax the request for appeal along with any appropriate clinical notes, laboratory, and imaging reports to be considered with the appeal to Qualis Health at 888-213-7516. CPT® codes and descriptions only are copyright 2015 American Medical Association

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NOTE: If the clinical information that is submitted is NEW (information obtained after the denial was issued), a new review will be initiated by Qualis Health and a new reference number will be assigned. An appeal will be conducted if the information submitted was available at the time of the initial review but not submitted. Upon receipt of a request for appeal, Qualis Health staff will review the documentation to determine if the appeal meets the medical necessity criteria. If it is determined that the appeal request does not meet the medical necessity criteria, the case will be referred to a physician to make a final determination. More information about Qualis Health's provider appeal process is available online at Qualis Health (Washington State Medicaid). If Qualis Health ultimately recommends the authorization be denied and Washington Apple Health (Medicaid) agrees, the client has the right to appeal to the Administrative Hearings Office.

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Authorization (WAC 182-531-0200) Authorization is the agency’s approval for covered services, equipment, or supplies before the services are provided to clients, as a precondition for provider reimbursement. Prior authorization (PA), expedited prior authorization (EPA), and limitation extensions (LE) are forms of authorization.

Prior authorization (PA) What is prior authorization (PA)? Prior authorization (PA) is the process the agency uses to authorize a service before it is provided to a client. The PA process applies to covered services and is subject to client eligibility and program limitations. Bariatric surgery is an example of a covered service that requires PA. PA does not guarantee payment. Note: For psychiatric inpatient authorizations, see the agency’s Inpatient Hospital Billing Provider Guide. Note: In addition to receiving PA, the client must be on an eligible program. For example, a client on the Family Planning Only program would not be eligible for bariatric surgery. For examples on how to complete a PA request, see Authorization for Services. Note: The agency reviews requests for payment for noncovered health care services according to WAC 182-501-0160 as an exception to rule (ETR).

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How does the agency determine PA? The agency reviews PA requests in accordance with WAC 182-501-0165. The agency uses evidence-based medicine to evaluate each request. The agency considers and evaluates all available clinical information and credible evidence relevant to the client’s condition. At the time of the request, the provider responsible for the client’s diagnosis or treatment must submit credible evidence specifically related to the client’s condition. Within 15 days of receiving the request from the client’s provider, the agency reviews all evidence submitted and will either: 

Approve the request.



Deny the request if the requested service is not medically necessary.



Request the provider to submit additional justifying information within 30 days. When the additional information is received, the agency will approve or deny the request within 5 business days of the receipt of the additional information. If the additional information is not received within 30 days, the agency will deny the requested service.

When the agency denies all or part of a request for a covered service or equipment, the agency sends the client and the provider written notice within 10 business days of the date the information is received that: 

Includes a statement of the action the agency intends to take.



Includes the specific factual basis for the intended action.



Includes references to the specific WAC provision upon which the denial is based.



Is in sufficient detail to enable the recipient to learn why the agency’s action was taken.



Is in sufficient detail to determine what additional or different information might be provided to challenge the agency’s determination.



Includes the client’s administrative hearing rights.



Includes an explanation of the circumstances under which the denied service is continued or reinstated if a hearing is requested.



Includes example(s) of lesser cost alternatives that permit the affected party to prepare an appropriate response.

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Services requiring PA (WAC 182-531-0200 (4)-(6)) The agency requires PA for the following:     

Abdominoplasty Bariatric surgery Eating disorders (diagnosis and treatment for clients age 21 and older) Elective surgical procedures (the agency may require a second opinion and/or consultation before authorizing) Hysterectomies and other surgeries of the uterus – see fee schedule for codes requiring PA (this policy applies to all ages) When requesting surgery, also indicate if the request is for assistant or co-surgeon. For further information, see the Centers for Medicare and Medicaid’s (CMS) Global Surgery Fact Sheet or CMS’s Claims Processing Manual for Physicians/Nonphysician Practitioners.

         

Inpatient hospital stays for acute physical medicine and rehabilitation (PM&R). Mometasone sinus implant (HCPCS code S1090) Oncotype DX (HCPCS code S3854) Osseointegrated/bone anchored hearing aids (BAHA) (for clients age 20 and younger) Osteopathic manipulative therapy (in excess of the agency's published limits) Molecular pathology tests as specified on the agency’s Physician-Related Services/Health Care Professional Services Fee Schedule Panniculectomy Removal or repair of previously implanted BAHA or cochlear device for clients age 21 older when medically necessary Hematopoietic progenitor cell boost (CPT® code 38243) Vagus nerve stimulator insertion For coverage, vagus nerve stimulator insertion must be performed in an inpatient or outpatient hospital facility and for reimbursement, providers must attach the invoice to the claim.



Intensity Modulated Radiation Therapy (IMRT) When requesting IMRT, providers must submit an initial request for treatment planning (CPT code 77301) to the agency. Once a treatment plan is established, the number of treatment units needed must be submitted to the existing prior authorization number using the process below. The agency expedites requests for treatment planning.

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To submit additional information to the request for IMRT, use the following instructions: 

Go to Document Submission Cover Sheets.



Scroll down and click on number 7. PA (Prior Authorization) Pend Forms.



When the form appears on the screen, insert the Authorization Reference number (ProviderOne authorization number) in the space provided and press enter to generate the barcode on the form.

TIP – The ProviderOne authorization number for this type of request can be found using the ProviderOne authorization inquiry feature. The ProviderOne authorization number is listed above the client's ID number on the PA Utilization screen. 

Print the Pend form and use it as the cover sheet to attach the additional information.



Fax all pages to the agency using the fax number on the bottom of the Pend form.

Note: The Pend form MUST be the first page of the fax. Submit a new treatment request only when:   

6 months has elapsed since the last request OR The treatment plan has changed.

The following surgical procedure codes require requires a medical necessity review by Qualis Health: Procedure Code 22899 23929 24999 27299 27599 29999

Short Description Spine surgery procedure Shoulder surgery procedure Upper arm/elbow surgery Pelvis/hip joint surgery Leg surgery procedure Arthroscopy of joint

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When requesting PA for surgical services where co-surgeons, a surgical team, or a surgical assistant are needed, include all the following: 1. 2. 3. 4. 5. 6.

The General Information for Authorization form, 13-835. One PA request per client. One Basic Information form, 13-756 for each surgeon. All appropriate modifier(s). Indicate in box 30 this is for co-surgeon, surgical team, or surgical assistant. Each surgeon’s billing NPI on the appropriate forms.

Documentation requirements for PA or LE PA Documentation For all requests for PA or LEs, the following documentation is required:

How do I obtain PA or an LE?



A completed, TYPED General Information for Authorization form, 13-835. This request form MUST be the initial page when of the request.



A completed Fax/Written Request Basic Information form, 13-756, if there is not a form specific to the service being requested, and all the documentation is listed on this form with any other medical justification.

Fax the request to: (866) 668-1214. See the agency’s Resources Available web page. Forms Available to Submit PA Requests       

Botulinum Toxin Provider Questionnaire, 13-003 Application for Chest Wall Oscillator, 13-841 Bariatric Surgery Request form, 13-785 Fax/Written Request Basic Information form, 13-756 Insomnia Referral Worksheet, 13-850 Oral Enteral Nutrition Worksheet, 13-743 Out of State Medical Services Request form, 13-787

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Physician-Related Services/Health Care Professional Services Forms Available to Submit PA Requests for Medication           

Acetaminophen Injection, J0131, use Basic Information form, 13-756 Alglucosidase alfa (lumizyme) 10 mg, J0221, use Basic Information form, 13-756 Belimumab injection, J0490, use Basic Information form, 13-756 Cimzia (Certolizumab pegol Inj.), J0718, use CIMZIA J0718 Request form, 13-885 Ceftaroline fosamil injection, J0712, use Fax/Written Request Basic Information form, 13-756 Ipilimumab injection, J9228, use Fax/Written Request Basic Information form, 13-756 Mannitol for inhaler, J7665, use Fax/Written Request Basic Information form, 13-756 Pegloticase injection, J2507, use Fax/Written Request Basic Information form, 13-756 Photofrin (Porfimer Sodium Inj.) 75mg, J9600, use Fax/Written Request Basic Information form, 13-756 Prolia (Denosumab Inj.), J0897, use Fax/Written Request Basic Information form, 13-756 Tysabri (Natalizumab Inj.) J2323, use TYSABRI J2323 Request form, 13-832

Written or fax prior authorization (PA) Written or fax PA is available to providers when a procedure’s EPA criteria have not been met or the covered procedure requires PA. Procedures that require PA are listed in the fee schedule. The agency does not retrospectively authorize any health care services that require PA after they have been provided except when a client has delayed certification of eligibility. When submitting a written or fax PA request, provide:   

The General Information for Authorization form, 13-835. This form must be page one of the mailed/faxed request and must be typed. The program form. This form must be attached to the request. Charts and justification to support the request for authorization.

Submit written or fax PA requests (with forms and documentation) to: 

By Fax: (866) 668-1214



By Mail: Authorization Services Office PO Box 45535 Olympia, WA 98504-5535

For a list of forms and where to send them, see Documentation for Prior Authorization. Be sure to complete all information requested. The agency returns incomplete requests to the provider.

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Submission of photos and X-rays for medical and DME PA requests For submitting photos and X-rays for medical and DME PA requests, use the FastLook™ and FastAttach™ services provided by Medical Electronic Attachment, Inc. (MEA). Register with MEA by:   

Going to www.mea-fast.com/. Selecting Provider Registration (on the menu bar below the banner). Entering “FastWDSHS” in the blue promotional code box.

Contact MEA at 888-329-9988, ext. 2, with any questions. When this option is chosen, fax the request to the agency and indicate the MEA# in the NEA field (box 18) on the PA Request form. There is an associated cost, which will be explained by the MEA services. Note: See the agency’s ProviderOne Billing and Resource Guide for more information on requesting authorization.

Limitation extension (LE) What is a limitation extension (LE)? A limitation extension (LE) is an authorization of services beyond the designated benefit limit allowed in Washington Administration Code (WAC) and agency provider guides. Note: A request for an LE must be appropriate to the client’s eligibility and/or program limitations. Not all eligibility groups cover all services.

How do I request an LE authorization? Some LE authorizations are obtained by using the EPA process. Refer to the EPA Criteria Coding List for criteria. If the EPA process is not applicable, an LE must be requested in writing and receive agency approval prior to providing the service. The written request must state all of the following: 1. 2. 3.

The name and ProviderOne Client ID of the client The provider’s name, ProviderOne Client ID, and fax number Additional service(s) requested CPT® codes and descriptions only are copyright 2015 American Medical Association

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The primary diagnosis code and CPT code Client-specific clinical justification for additional services

Expedited prior authorization (EPA) What is expedited prior authorization (EPA)? Expedited prior authorization (EPA) is designed to eliminate the need for written authorization. The agency establishes authorization criteria and identifies the criteria with specific codes, enabling providers to create an EPA number using those codes. To bill the agency for diagnostic conditions, procedures and services that meet the EPA criteria on the following pages, the provider must create a 9-digit EPA number. The first five or six digits of the EPA number must be 87000 or 870000. The last 3 or 4 digits must be the code assigned to the diagnostic condition, procedure, or service that meets the EPA criteria (see EPA Criteria Coding List for codes). Enter the EPA number on the billing form in the authorization number field, or in the Authorization or Comments section when billing electronically. Example: The 9-digit authorization number for a client with the following criteria would be 870000421: Client is age 11 through 55 and is in one of the at-risk groups because the client meets one of the following: 1) 2) 3) 4)

Has terminal complement component deficiencies Has anatomic or functional asplenia Is a microbiologist who is routinely exposed to isolates of Neisseria meningitis Is a freshman entering college who will live in a dormitory

The agency denies claims submitted without a required EPA number. The agency denies claims submitted without the appropriate diagnosis, procedure code, or service as indicated by the last three digits of the EPA number. The billing provider must document in the client’s file how the EPA criteria were met and make this information available to the agency on request. If the agency determines the documentation does not support the criteria being met, the claim will be denied. Note: The agency requires written/fax PA when there is no option to create an EPA number.

CPT® codes and descriptions only are copyright 2015 American Medical Association

305

Physician-Related Services/Health Care Professional Services

EPA guidelines Documentation The provider must verify medical necessity for the EPA number submitted. The client’s medical record documentation must support the medical necessity and be available upon the agency’s request. If the agency determines the documentation does not support the EPA criteria requirements, the claim will be denied. Note: For enteral nutrition EPA requirements, refer to the Prior Authorization section in the agency’s Enteral Nutrition Provider Guide.

EPA Criteria Coding List A complete EPA number is 9 digits. The first five or six digits of the EPA number must be 87000 or 870000. The last 3 or 4 digits must be the code assigned to the diagnostic condition, procedure, or service that meets the EPA criteria. If the client does not meet the EPA criteria, prior authorization (PA) is required (see Prior Authorization).

CPT® codes and descriptions only are copyright 2015 American Medical Association

306

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

870000-

051

Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina.

CPT code: 92134 Limit to 12 per calendar year. The client must meet both of the following criteria: 

The client is undergoing active treatment (intraocular injections, laser or incisional surgery) for conditions such as cystoid macular edema (CME); choroidal neovascular membrane (CNVM) from any source (active macular degeneration (AMD) in particular); diabetic retinopathy or macular edema; retinal vascular occlusions; epiretinal membrane; vitromacular traction; macular holes; unstable glaucoma; multiple sclerosis with visual symptoms; optic neuritis; optic disc drusen; optic atrophy; eye toxicity or side-effects related to medication use; papilledema or pseudopapilledema



241

Reduction Mammoplasties/ Mastectomy for Gynecomastia

There is documentation in the client’s record describing the medical circumstance and explaining the need for more frequent services. A female with a diagnosis for hypertrophy of the breast with:

CPT codes: 19318, 19300 Dx codes: N62, N64.9, or L13.9

1) Photographs in client's chart 2) Documented medical necessity including: a) Back, neck, and/or shoulder pain for a minimum of one year, directly attributable to macromastia b) Conservative treatment not effective 3) Abnormally large breasts in relation to body size with shoulder grooves 4) Within 20% of ideal body weight, and 5) Verification of minimum removal of 500 grams of tissue from each breast

CPT® codes and descriptions only are copyright 2015 American Medical Association

307

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

870000-

242

421

Reduction Mammoplasties/ Mastectomy for Gynecomastia

CPT codes: 19318, 19300

A male with a diagnosis for gynecomastia with:

Dx codes: N62, N64.9, or L13.9

1) Pictures in clients' chart 2) Persistent tenderness and pain 3) If history of drug or alcohol abuse, must have abstained from drug or alcohol use for no less than one year

Meningococcal Vaccine

CPT: 90734 (Conjugate Vaccine – Menactra®)

Client is age 19 through 552 and is in one of the at-risk groups because the client meets one of the following: 1) Not routinely recommended for ages 1921, but may be administered as catch-up vaccination for those who have not received a dose after their 16th birthday 2) Has persistent complement deficiencies 3) Has anatomic or functional asplenia 4) Are at risk during a community outbreak attributable to a vaccine serogroup 5) Infected with human immunodeficiency virus (HIV), if another indication for vaccination exists 6) Is a microbiologist who is routinely exposed to isolates of N. meningitidis 7) Is a freshman entering college who will live in a dormitory

2

For clients age 11 through 20, see the agency’s EPSDT Provider Guide. CPT® codes and descriptions only are copyright 2015 American Medical Association

308

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

870000-

422

423

Placement of Drug Eluting Stent and Device

Unilateral cochlear implant for clients age 20 and younger

HCPCS codes: C1874, C1875, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 (837I/UB-04 only)

Drug eluting stents must be:

CPT: 69930

The agency pays for cochlear implantation only when the products come from a vendor with a Core Provider Agreement with the agency, there are no other contraindications to surgery, and

1) Medically necessary and 2) One or more of the following criteria are met: a) Stent diameter is 3 mm or less b) Length of stent(s) is longer than 15 mm placed within a single vessel c) Stents are placed to treat in-stent restenosis d) For patients with diabetes mellitus e) For treatment of left main coronary disease

Note: See EPA #870001365 for criteria for bilateral cochlear implantation. One of the following must be true: 1) Unilateral cochlear implantation for clients age 18 through 20 with postlingual hearing loss and clients (12 months-17 years old) with prelingual hearing loss when all of the following are true: a) The client has a diagnosis of profound to severe bilateral, sensorineural hearing loss b) The client has stimulable auditory nerves but has limited benefit from appropriately fitted hearing aids (e.g., fail to meet age-appropriate auditory milestones in the bestaided condition for young children, CPT® codes and descriptions only are copyright 2015 American Medical Association

309

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

870000-

or score of less than ten or equal to 40% correct in the best-aided condition on recorded open-set sentence recognition tests c) The client has the cognitive ability to use auditory clues d) The client is willing to undergo an extensive rehabilitation program e) There is an accessible cochlear lumen that is structurally suitable for cochlear implantation f) The client does not have lesions in the auditory nerve and/or acoustic areas of the central nervous system Note: See the agency’s Hearing Hardware for Clients 20 Years of Age and Younger Provider Guide for replacement parts for cochlear implants. 424

Meningococcal Vaccine

CPT codes: 90733 (Polysaccharide vaccine – Menomune®)

Client must meet at least 1 of the 5 criteria for use of the meningococcal vaccine outlined for EPA #870000421 (CPT code 90734) and one of the following is true: 1) The client is one of the following: a) 2 years of age through 10 years of age b) Older than 55 years of age 2) The conjugate vaccine is not available.

CPT® codes and descriptions only are copyright 2015 American Medical Association

310

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

870000-

425

Hyperbaric Oxygen Therapy

CPT code: 99183 All of the following must be true: HCPCS code: G0277 (837I/UB04 only)

610

Visual Exam/Refraction (Optometrists/Ophth almologists only)

CPT codes: 92014-92015



The diagnosis must be listed in the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals for this EPA number.  Patient has type 1 or type 2 diabetes and has a lower extremity wound that is due to diabetes  Patient has a wound classified as Wagner grade 3 or higher  Hyperbaric oxygen therapy is being done in combination with conventional diabetic wound care Eye Exam/Refraction - Due to loss or breakage: For adults within 2 years of last exam when no medical indication exists and both of the following are documented in the client’s record: 1) Glasses are broken or lost or contacts that are lost or damaged 2) Last exam was at least 18 months ago Note: EPA # is not required when billing for children or clients with developmental disabilities.

630

Blepharoplasties

CPT codes: 15822, 15823, and 67901-67908

Blepharoplasty for noncosmetic reasons when both of the following are true: 1) The excess upper eyelid skin impairs the vision by blocking the superior visual field 2) On a central visual field test, the vision is blocked to within 10 degrees of central fixation

CPT® codes and descriptions only are copyright 2015 American Medical Association

311

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

870000-

631

Strabismus Surgery

Strabismus surgery for clients 18 years of age and older when both of the following are true:

CPT codes: 67311-67340 Dx Code: H53.2

1) The client has a strabismus-related double vision (diplopia) and 2) It is not done for cosmetic reasons

EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

87000-

For Neuropsychological testing, see the Mental Health Services Provider Guide. Injection, 1300 HCPCS code: All of the following must apply: Romiplostim, 10 J2796 Microgram 1) Documented diagnosis of Idiopathic Thrombocytopenic Purpura (ITP) 2) Patient must be at least 18 years of age 3) Inadequate response (reduction in bleeding) to: a. Immunoglobulin treatment b. Corticosteroid treatment or c. Splenectomy

CPT® codes and descriptions only are copyright 2015 American Medical Association

312

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

87000-

1302

1303

Hysterectomies for Cancer

Hysterectomies Complications and Trauma

CPT codes: 58150, 58152, 58180, 58200, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58545, 58546, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573 CPT codes: 58150, 58152, 58180, 58200, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58545, 58546, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573,

Client must have a diagnosis of cancer requiring a hysterectomy as part of the treatment plan** See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals for this EPA number.

Client must have a complication related to a procedure or trauma (e.g., postprocedure complications; postpartum hemorrhaging requiring a hysterectomy; trauma requiring a hysterectomy) See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals for this EPA number.

CPT® codes and descriptions only are copyright 2015 American Medical Association

313

Physician-Related Services/Health Care Professional Services EPA Code

Service Name

CPT/HCPCS/Dx

Criteria

87000-

1312

Continuous Glucose Monitoring (CGM)

CPT codes: 95250, 95251

Allowed only for clients 18 years of age and younger for the in-home use of professional or diagnostic CGM for a 72-hour period. The client must:  Have diabetes mellitus (DM).  Be insulin dependent.  Have had one or more severe episodes of hypoglycemia (blood glucose less than or equal to 50 mg/dl) *requiring assistance from another person, or complicated by a hypoglycemia-induced seizure. The CGM must be:  Ordered by a pediatrician.  Provided by an FDA-approved CGM device. Verification with self-monitoring of blood glucose (SMBG) is needed prior to adjusting insulin. Do not use the CGM results to adjust insulin. Limit: 2 monitoring periods of 72 hours each, per client, every 12 months. *Requiring assistance means that the client does not recognize the symptoms of hypoglycemia and/or is unable to respond appropriately.

CPT® codes and descriptions only are copyright 2015 American Medical Association

314

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Intensity Modulated 1313 Radiation Therapy (IMRT)

CPT/HCPCS/ Dx CPT codes: 77301, 77338, 77370, G6015, G6016 Dx code: C61

Criteria Head and neck cancers: Dx: See the agency’s Program Policy Approved Diagnosis Codes for PhysicianRelated Services/Health Care Professionals for this EPA number. All other diagnoses require prior authorization. Prostate cancer  As primary treatment for prostate cancer without prostatectomy and without metastases as primary therapy or in combination with brachytherapy  For post-prostatectomy treatment (Prostate bed or whole pelvis) of prostate cancer without metastases as adjuvant radiation therapy immediately following prostatectomy  Salvage therapy for failed primary treatment  Salvage therapy for failed prostatectomy (positive margins, positive lymph nodes, or confirmed failure of PSA to fall to undetectable levels)  Salvage therapy for suspected recurrence of localized prostate cancer  All other clinical presentations require prior authorization To spare adjacent critical structures, use EPA #870001374.

1321

Orencia (abatacept)

HCPCs code: J0129

Treatment of rheumatoid arthritis when prescribed by a rheumatologist in patients who have tried and failed one or more DMARDs. Dose is subcutaneous injection once weekly. IV dosing is up to 1000mg dose to start, repeated at week 2 and 4, then maintenance up to 1000mg every 4 weeks.

CPT® codes and descriptions only are copyright 2015 American Medical Association

315

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Targeted TB testing 1325 with interferongamma release assays

CPT/HCPCS/ Dx

Criteria Targeted TB testing with interferon-gamma release assays may be considered medically necessary for clients five years of age and older for any of the following conditions:

CPT codes: 86480, 86481

 History of positive tuberculin skin test or previous treatment for TB disease  History of vaccination with BCG (Bacille Calmette-Guerin)  Recent immigrants (within 5 years) from countries that have a high prevalence of tuberculosis  Residents and employees of high-risk congregate settings (homeless shelters, correctional facilities, substance abuse treatment facilities)  Clients with an abnormal CXR consistent with old or active TB  Clients undergoing evaluation or receiving TNF alpha antagonist treatment for rheumatoid arthritis, psoriatic arthritis, or inflammatory bowel disease AND  Client in agreement to remain in compliance with treatment for latent tuberculosis infection if found to have a positive test. The tuberculin skin test is the preferred method of testing for children under the age of 5.

CPT® codes and descriptions only are copyright 2015 American Medical Association

316

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Alloderm 1342

CPT/HCPCS/ Dx

Criteria All of the following must be met:

CPT code: Q4116

 It is medically necessary  The client has a diagnosis of breast cancer  The servicing provider is either a general surgeon or a plastic surgeon 1344

Noninvasive prenatal diagnosis of fetal aneuploidy (NIPT)

The agency considers NIPT for serum marker screening for fetal aneuploidy to be medically necessary in women with high-risk singleton pregnancies, who have had genetic counseling, when one or more of the following are met:

CPT code: 81507

 Pregnant woman is age 35 years or older at the time of delivery  History of a prior pregnancy with a trisomy or aneuploidy  Family history of aneuploidy (first degree relatives or multiple generations affected)  Positive first or second trimester standard biomarker screening test for aneuploidy, including sequential, or integrated screen, or a positive quadruple screen  Parental balanced Robertsonian translocation with increased risk for fetal T13 or T21 1350

Transient elastograph

All of the following must be met:

CPT code: 91200

  

Baseline detectable HCV RNA viral load Chronic hepatitis C virus infection and BMI < 30 Both APRI (AST to platelet ratio index) and FibroSURE™ tests have been completed with the following results: FibroSURE™ < 0.49 and APRI > 1.5 or FibroSURE™> 0.49 and APRI < 1.5

CPT® codes and descriptions only are copyright 2015 American Medical Association

317

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Interoperative or 1351 postoperative pain control using a spinal injection or infusion Low dose CT for 1362 lung cancer screen

CPT/HCPCS/ Dx

Criteria

CPT codes: 62310, 62311, 62318, 62319

These CPT codes may be billed with this EPA when they are done interoperatively or postoperatively for pain control.

HCPCS code: S8032

The client must meet all of the following criteria:  Is age 55-80 and  Has a history of smoking 30 packs a year and still smokes or  Has a history of smoking 30 packs a year and has quit smoking in the last 15 years

1363

Bone mineral density testing with dual x-ray absorptiometry (DXA) - initial screening

Bone mineral density testing with dual x-ray CPT codes: 77080 and 77081 absorptiometry (DXA) is a covered benefit with the following conditions: Asymptomatic women  Women 65 years of age and older or  Women 64 years of age and younger with equivalent ten year fracture risk to women age 65 as calculated by FRAX (Fracture Risk Assessment) tool or other validated scoring tool Men or women  Long term glucocorticoids (i.e. current or past exposure to glucocorticoids for more than 3 months) or  Androgen deprivation or other conditions known to be associated with low bone mass

CPT® codes and descriptions only are copyright 2015 American Medical Association

318

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Bone mineral 1364 density testing with dual x-ray absorptiometry (DXA) - repeat test

CPT/HCPCS/ Dx

Criteria

Repeat bone mineral density testing with dual CPT codes: 77080 and 77081 x-ray absorptiometry (DXA) is a covered benefit when the client meets one of the following:   

T-score** > -1.5, 15 years to next screening test T-score -1.5 to -1.99, 5 years to next screening test T-score ≤ -2.0, 1 year to next screening test

Or 

1365

Bilateral cochlear implants

Use of medication associated with low bone mass or presence of a condition known to be associated with low bone mass The client must:

CPT: 69930 Modifier: 50

 Be age 12 months through 20 years old  Have bilateral severe to profound sensorineural hearing loss. See qualifying diagnoses as listed in the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals for this EPA number.  Be limited or no benefit from hearing aids  Have cognitive ability and willingness to participate in an extensive auditory rehabilitation program  Have freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system  Have no other contraindications for surgery  Use device in accordance with the FDA approved labeling

See EPA#870000423 for unilateral cochlear implants

CPT® codes and descriptions only are copyright 2015 American Medical Association

319

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Testosterone testing 1368

CPT/HCPCS/ Dx CPT: 84402, 84403

Criteria For males age 19 and older and at least one of the following conditions are met:  Suspected or known primary hypogonadism  Suspected or known secondary hypogonadism with organ causes such as:  Pituitary disorder  Suprasellar tumor  Medications suspected to cause hypogonadism  HIV with weight loss  Osteoporosis  Monitoring of testosterone therapy

1369

Professional services provided to an MCO client during the BHO authorized admission

All of the following conditions must be met:  The client’s inpatient hospital (POS 21, 51) admission was authorized by the BHO  The client’s primary diagnosis is in the psychiatric range. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals for this EPA number.  The services are provided by a psychiatrist, psychologist, or psychiatric ARNP

CPT® codes and descriptions only are copyright 2015 American Medical Association

320

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Professional services 1370 rendered in the ER to an MCO client

1371

1372

1373

1374

Orthoptic/pleoptic training

Orthoptic/pleoptic training

Orthoptic/pleoptic training

Intensity modulated radiation therapy (IMRT)

CPT/HCPCS/ Dx

Criteria All of the following conditions must be met:  The client is seen in the ER (POS 23)  The client was transferred to a different hospital for an inpatient admission that was authorized by the BHO  The client’s primary diagnosis is in the psychiatric range. See the agency’s Program Policy Approved Diagnosis Codes for Physician-Related Services/Health Care Professionals for this EPA number.

CPT: 97110 Dx: H50.411 or H50.412 with secondary dx of TBI CPT: 97112 Dx: H51.12 with secondary dx of TBI CPT: 97530 Dx: H53.30 with secondary dx of TBI CPT: 77301, 77338, 77370, G6015, G6016

Documented diagnosis of convergence insufficiency, convergence excess, or binocular dysfunction, with a secondary diagnosis of traumatic brain injury (TBI)

Documented diagnosis of convergence insufficiency, convergence excess, or binocular dysfunction, with a secondary diagnosis of traumatic brain injury (TBI) Documented diagnosis of convergence insufficiency, convergence excess, or binocular dysfunction with a secondary diagnosis of traumatic brain injury (TBI) If the IMRT is performed to spare adjacent critical structures to prevent toxicities within expected life span. The critical structures spared through the use of IMRT must be clearly documented in the client’s medical record.

CPT® codes and descriptions only are copyright 2015 American Medical Association

321

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Early elective 1375 delivery or natural delivery prior to 39 weeks gestation

1378

Elective delivery or natural delivery at or over 39 weeks gestation

1381

HPV genotyping

CPT/HCPCS/ Dx

Criteria

CPT: 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622

Client is under 39 weeks gestation and the mother or fetus has a diagnosis listed in the Joint Commission’s current table of Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation, or mother delivers naturally.

CPT: 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622 CPT: 87625

Client is 39 weeks gestation or over 39 weeks gestation.

For females age 30 and older, when the following conditions are met:  

Pap negative and HPV positive Pap no EC/TZ and HPV positive

CPT® codes and descriptions only are copyright 2015 American Medical Association

322

Physician-Related Services/Health Care Professional Services EPA Code Service Name 87000Tympanostomy 1382 tubes

CPT/HCPCS/ Dx 69433 or 69436

Criteria The client is age 16 or younger and is: Diagnosed with acute otitis media (AOM) and the client:  Has complications or is immunocompromised or is at risk for infection OR  Has had 3 episodes of AOM in the last 6 months with one occurring in the last 6 months and  Has the presence of effusion at the time of assessment for surgical candidacy

OR The client is diagnosed with otitis media with effusion (OME) and the client has:  An effusion for 3 months or greater and there is documented hearing loss

OR 

A disproportionate risk from the effects of hearing loss, such as those with speech delay, underlying sensory-neuro hearing loss or cognitive disorders

CPT® codes and descriptions only are copyright 2015 American Medical Association

323

Physician-Related Services/Health Care Professional Services

Modifiers (WAC 182-531-1850(10) and (11))

CPT/HCPCS Italics indicate additional agency language not found in CPT. 22:

Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure code number. This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight or trauma. For informational purposes only; no extra allowance is allowed.

23:

Unusual Anesthesia: For informational purposes only; no extra allowance is allowed.

24:

Unrelated Evaluation and Management (E/M) by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service. Payment for the E/M service during postoperative period is made when the reason for the E/M service is unrelated to original procedure.

25:

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure: The physician may need to indicate that on the day a procedure or service identified by a CPT® code was performed, the client’s condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. Payment for the E/M service is the billed charge or the agency’s maximum allowable, whichever is less.

26:

Professional Component: Certain procedures are a combination of professional and technical components. When only the professional component is reported, the service is identified by adding modifier 26 to the procedure code.

TC:

Technical Component: Certain procedures are a combination of professional and technical components. When only the technical component is reported, the service is identified by adding modifier TC to the procedure code. In order to receive payment, a contract with the agency is required if services are performed in a hospital setting. CPT® codes and descriptions only are copyright 2015 American Medical Association

324

Physician-Related Services/Health Care Professional Services 32:

Mandated Services: For informational purposes only; no extra allowance is allowed.

47:

Anesthesia by Surgeon: Not covered by the agency.

50:

Bilateral Procedure: Unless otherwise identified in the listing, bilateral procedures that are performed at the same operative session should be identified by adding this modifier to the appropriate five-digit code describing the first procedure. For surgical procedures typically performed on both sides of the body, payment for the E/M service is the billed charge or the agency’s maximum allowable, whichever is less. For surgical procedures that are typically performed on one side of the body, but performed bilaterally in a specific case, payment is 150% of the global surgery fee for the procedure.

51:

Multiple Procedures: When multiple surgeries are performed at the same operative session, total payment is equal to the sum of the following: 100% of the highest value procedure; 50% of the global fee for each of the second through fifth procedures. More than five procedures require submission of documentation and individual review to determine the payment amount.

52:

Reduced Services: Under certain circumstances, a service or procedure is partially reduced at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Using this modifier does not reduce the allowance to the provider. Note: Modifier 52 may be used with computerized tomography procedure codes for a limited study or a follow-up study.

53:

Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Use of modifier 53 is allowed for all surgical procedures. Modifier 53 is a payment modifier when used with CPT code 45378 and HCPCS codes G0105 and G0121 only. It is information only for all other surgical procedures.

54, 55, 56 – Providers providing less than the global surgical package should use modifiers 54, 55, & 56. These modifiers are designed to ensure that the sum of all allowances for all practitioners who furnished parts of the services included in a global surgery fee do not exceed the total amount of the payment that would have been paid to a single practitioner under the global fee for the procedure. The payment policy pays each physician directly for that portion of the global surgery services provided to the client. The breakdown is as follows:

CPT® codes and descriptions only are copyright 2015 American Medical Association

325

Physician-Related Services/Health Care Professional Services 54:

Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. A specific percentage of the global surgical payment in the fee schedule is made for the surgical procedure only.

55:

Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number. A specific percentage of the global surgical payment in the fee schedule is made for the surgical procedure only.

56:

Preoperative Management Only: When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure, the preoperative component may be identified by adding the modifier 56 to the usual procedure number. A specific percentage of the global surgical payment in the fee schedule is made for the surgical procedure only.

57:

Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

58:

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure. Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier 78.

59:

Distinct Procedural Service: Modifier 59 should be used only if no other more specific modifier is appropriate. Effective January 1, 2015, use modifiers XE, XS, XP, and XU in lieu of modifier 59 whenever possible. These modifiers were developed by CMS to provide greater reporting specificity in situations where modifier 59 was previously reported. The physician must indicate that a procedure or service was distinct or separate from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, separate lesion, or separate injury (or area of surgery in extensive injuries).

62:

Two Surgeons: Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances, separate services may be identified by adding modifier 62 to the procedure code used by each surgeon for reporting his/her services. Payment for this modifier is 125% of the global surgical fee in the fee schedule. The payment is divided equally between the two surgeons. No payment is made for an assistant surgeon.

66:

Team surgery: For informational purposes only; no extra allowance is allowed. CPT® codes and descriptions only are copyright 2015 American Medical Association

326

Physician-Related Services/Health Care Professional Services 76:

77:

Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated. This may be reported by adding the modifier 76 to the repeated service. Repeat Procedure by Another Physician: For informational purposes only; no extra allowance is allowed.

78:

Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier 78 to the related procedure. When multiple procedures are performed, use modifier 78 on EACH detail line. Payment for these procedures is the percentage of the global package for the intra-operative services. Assistant surgeons and anesthesiologists must use modifier 99 to indicate an additional operating room procedure.

79:

Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79.

80:

Assistant Surgeon: Surgical assistant and/or physician assistant services must be identified by adding modifier 80 to the usual procedure code(s).

81:

Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding the modifier 81 to the usual procedure number. Payment is 20% of the maximum allowance.

82:

Assistant Surgeon (When Qualified Resident Surgeon Not Available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). Payment is 20% of the maximum allowance.

90:

Reference (Outside) Laboratory: When laboratory procedures are performed by a lab other than the referring lab, the procedure must be identified by adding modifier 90 to the procedure code. The reference lab NPI must be entered in the performing number field on the CMS-1500 claim form (version 02/12) or electronic claim record. The reference lab must be CLIA-certified.

91:

Repeat Clinical Diagnostic Laboratory Test performed on the same day to obtain subsequent report test value(s). Modifier 91 must be used when repeat tests are performed on the same day, by the same provider to obtain reportable test values with separate specimens taken at different times, only when it is necessary to obtain multiple results in the course of treatment. When billing for a repeat test, use modifier 91 with the appropriate procedure code.

99:

Multiple Modifiers: The ProviderOne system can read up to four modifiers on a professional transaction. Add modifier 99 only if there are more than four modifiers to be CPT® codes and descriptions only are copyright 2015 American Medical Association

327

Physician-Related Services/Health Care Professional Services added to the claim line. If there are four or fewer modifiers on a claim line, do not add modifier 99. AS:

Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery.

CG

Policy criteria applied

FP

Service provided as part of Family Planning Program

GB

Claim being resubmitted for payment because it is no longer under a global payment demonstration

HA

Child/Adolescent program

LT

Left Side: Used to identify procedures performed on the left side of the body. The agency requires this modifier with some procedure codes for proper payment.

QP

Documentation is on file showing that the lab test(s) was ordered individually or ordered as a CPT recognized panel other than automated profile codes. This modifier is now used FOR INFORMATION ONLY. Internal control payment methodology for automated multi-channel test is applied. This modifier is not appropriate to use when billing for repeat tests or to indicate not as a panel.

Q6

Physician Services: Services furnished by a locum tenens physician. For informational purposes only; no extra allowance is allowed.

RT

Right Side: Used to identify procedures performed on the right side of the body. The agency requires this modifier with some procedure codes for proper payment.

SL

State-Supplied Vaccine: This modifier must be used with procedure codes for immunization materials obtained from the Department of Health (DOH).

ST

Related to Trauma or Injury

TC:

Technical Component: Certain procedures are a combination of professional and technical components. When only the technical component is reported, the service is identified by adding modifier TC to the procedure code. In order to receive payment, a contract with the agency is required if services are performed in a hospital setting.

TG

Complex/high level of care.

TH

Obstetrical treatment/services, prenatal or postpartum: Use this modifier for unbundling maternity care for 1-3 visits. See Billing with modifiers.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services TJ

Child/Adolescent Program: To be used for enhancement payment for foster care children screening exams.

TS

Follow-up service: To be used with HCPCS procedure code H0009 and for selected Applied Behavior Analysis (ABA) services (see the agency’s Mental Health Services Provider Guide).

UA

Medicaid Care Lev 10 State Def.

UN

Two patients served: To be used with CPT code R0075.

UP

Three patients served: To be used with CPT code R0075.

UQ

Four patients served: To be used with CPT code R0075.

UR

Five patients served: To be used with CPT code R0075.

US

Six or more patients served: To be used with CPT code R0075.

Effective January 1, 2015, use the following modifiers which were developed by CMS to provide greater reporting specificity in situations where modifier 59 was previously reported. Use these modifiers in lieu of modifier 59 whenever possible: XE

Separate encounter: A service that is distinct because it occurred during a separate encounter. This modifier is used only to describe separate encounters on the same date of service.

XS

Separate structure: A service that is distinct because it was performed on a separate organ/structure.

XP

Separate practitioner: A service that is distinct because it was performed by a different practitioner.

XU

Unusual non-overlapping service: A service that is distinct because it does not overlap usual components of the main service.

Anesthesia AA

Anesthesia services personally furnished by an anesthesiologist. This includes services provided by faculty anesthesiologists involving a physician-in-training (resident). Payment is 100% of the allowed amount. Modifier AA must not be billed in combination with QX. CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services When supervising, the physician must use one of the modifiers below. Payment for these modifiers is 50% of the allowed amount. Modifier QX must be billed by the Certified Registered Nurse Anesthetist (CRNA). AD

Medical supervision by a physician for more than four concurrent anesthesia services.

QK

Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.

QS

Monitored anesthesia services. To bill for monitored anesthesia care services, the following applies: If the physician personally performs the case, modifier AA must be used and payment is 100% of the allowed amount. If the physician directs four or fewer concurrent cases and monitored care represents two or more of the case modifiers, modifier QK must be used and payment is 50% of the allowed amount. QS modifier must be used in the second modifier position in conjunction with a pricing anesthesia modifier in the first modifier position.

QX

CRNA service with medical direction by a physician should be used when under the supervision of a physician. Payment is 50% of the allowed amount. This modifier is payable in combination with Modifiers AD or QK, which is used by the supervising anesthesiologist. Modifier QX must not be billed in combination with AA.

QY

CRNA and anesthesiologist are involved in a single procedure and the physician is performing the medical direction. The physician must use modifier QY and the medically directed CRNA must use modifier QX. The anesthesiologist and CRNA each receive 50% of the allowance that would have been paid had the service been provided by the anesthesiologist or CRNA alone.

QZ

CRNA service without medical direction by a physician. Must be used when practicing independently. Payment is 100% of the allowed amount. This modifier must not be billed in combination with any other modifier.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Site-of-Service Payment Differential How are fees established for professional services performed in facility and nonfacility settings? Based on the Resource Based Relative Value Scale (RBRVS) methodology, the agency's fee schedule amounts are established using three relative value unit (RVU) components: work, practice expense, and malpractice expense. The agency uses two levels of practice expense components to determine the fee schedule amounts for reimbursing professional services. This may result in two RBRVS maximum allowable fees for a procedure code. These are: 

Facility setting maximum allowable fees (FS Fee) - Paid when the provider performs the services in a facility setting (e.g., a hospital or ambulatory surgery center) and the cost of the resources are the responsibility of the facility.



Nonfacility setting maximum allowable fees (NFS Fee) - Paid when the provider performs the service in a nonfacility setting (e.g., office or clinic) and typically bears the cost of resources, such as labor, medical supplies, and medical equipment associated with the service performed.

Some services, by nature of their description, are performed only in certain settings and have only one maximum allowable fee per code. Examples of these services include: 

Evaluation and management (E/M) codes which specify the site-of-service (SOS) within the description of the procedure codes (e.g., initial hospital care)



Major surgical procedures that are generally performed only in hospital settings

How does the SOS payment policy affect provider payments? Providers billing professional services are paid at one of two maximum allowable fees, depending on where the service is performed.

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Physician-Related Services/Health Care Professional Services

Does the agency pay providers differently for services performed in facility and nonfacility settings? Yes. When a provider performs a professional service in a facility setting, the agency makes two payments - one to the performing provider and another to the facility. The payment to the provider (FS Fee) includes the provider’s professional services only. A separate payment is made directly to the facility where the service took place, which includes payment for necessary resources. The FS Fee excludes the allowance for resources that are included in the payment to the facility. Paying the lower FS Fee to the performing provider when the facility is also paid eliminates duplicate payment for resources. When a provider performs a professional service in a nonfacility setting, the agency makes only one payment to the performing provider. The payment to the provider (NFS Fee) includes the provider’s professional services and payment for necessary resources.

When are professional services paid at the facility setting maximum allowable fee? Providers are paid at the FS Fee when the agency also makes a payment to a facility. In most cases, the agency follows Medicare’s determination for using the FS Fee. Professional services billed with the following place of service codes are paid at the FS Fee: FACILITY SETTING Place of Service Code 06 08 19 21 22 23 24 25 26 31

Place of Service Description Indian Health Service – provider based Tribal 638 – provider based Off Campus-Outpatient Hospital Inpatient Hospital Outpatient Hospital Emergency Room – Hospital Ambulatory Surgery Center Birthing Center Military Treatment Facility Skilled Nursing Facility

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Physician-Related Services/Health Care Professional Services FACILITY SETTING (cont.) Place of Service Code 34 51 52 53 56 61 62

Place of Service Description Hospice Inpatient Psychiatric Facility Psychiatric Facility Partial Hospitalization Community Mental Health Center Psychiatric Residential Treatment Center Comprehensive Inpatient Rehabilitation Facility Comprehensive Outpatient Rehabilitation Facility

Note: All claims submitted to the agency must include the appropriate Medicare two-digit place of service code. The agency will deny claims with single-digit place of service codes. Due to Medicare’s consolidated billing requirements, the agency does not make a separate payment to providers who perform certain services in hospitals and skilled nursing facilities. The facilities are paid at the NFS Fee. Some therapies, such as physical therapy services (CPT® codes 97001-97799), are always paid at the NFS Fee.

When are professional services paid at the nonfacility setting maximum allowable fee? The NFS Fee is paid when the agency does not make a separate payment to a facility, such as when services are performed in a provider’s office or a client’s home. In most cases, the agency follows Medicare’s determination for using the NFS Fee. Professional services billed with the following place of service codes are paid at the NFS Fee: NONFACILITY SETTING Place of Service Code 04 05 07 11 12 13 14 15 20 32

Place of Service Description Homeless Shelter Indian Health – Free Standing Tribal 638 – Free Standing Office Home Assisted Living Facility Group Home Mobile Unit Urgent Care Facility Nursing Facility

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services NONFACILITY SETTING (cont.) Place of Service Code 33 49 50 54 55 57 60 65 71 72 81 99

Place of Service Description Custodial Care Facility Independent Clinic Federally Qualified Health Center Intermediate Care Facility Residential Substance Abuse Treatment Facility Nonresident Substance Abuse Treatment Facility Mass Immunization Center End-Stage Renal Disease Treatment Facility State or Local Public Health Clinic Rural Health Clinic Independent Laboratory Other Place of Service

Note: All claims submitted to the agency must include the appropriate Medicare two-digit place of service code. The agency will deny claims with single-digit place of service codes.

Which professional services have a SOS payment differential? Most of the services with an SOS payment differential are from the surgery, medicine, and E/M ranges of CPT codes. However, some HCPCS, CPT radiology, pathology, and laboratory codes also have an SOS payment differential.

When are primary care providers paid at the Medicare rate? The agency discontinued this rate increase effective for claims with dates of service on and after January 1, 2015. This provision was applied to evaluation and management services and vaccine administration services provided by a physician (or under his/her personal supervision) who had filed an attestation with the agency.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

When are independent ARNPs eligible for a rate increase and which services apply? The agency discontinued this rate increase effective for claims with dates of service on and after January 1, 2015. Eligible providers were independent ARNPs who were not supervised by an eligible primary care physician and who were not already receiving increased rates for E/M services and vaccine administration services were provided under the Affordable Care Act, section 1202.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Fee Schedule Information 

Maximum allowable fees for all codes, including CPT® codes and selected HCPCS codes, are listed in the fee schedule.



In the fee schedule, the agency identifies procedure codes that may require prior authorization. However, this list may not be all-inclusive. Prior authorization, limitations, or requirements detailed in agency provider guides and Washington Administrative Code (WAC) remain applicable.



The agency’s fee schedules are available for download in Microsoft Excel.

CPT® codes and descriptions only are copyright 2015 American Medical Association

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Physician-Related Services/Health Care Professional Services

Billing and Claim Form What are the general billing requirements? Providers must follow the agency ProviderOne Billing and Resource Guide. These billing requirements include, but are not limited to:       

Time limits for submitting and resubmitting claims and adjustments. What fee to bill the agency for eligible clients. When providers may bill a client. How to bill for services provided to primary care case management (PCCM) clients. Billing for clients eligible for both Medicare and Medicaid. Third-party liability. Record keeping requirements.

Billing for multiple services If multiples of the same procedures are performed on the same day, providers must bill with the appropriate modifier (if applicable) and must bill all the services on the same claim form to be considered for payment.

Billing for outpatient hospital services in hospital-based clinics The agency requires clinics to bill for outpatient services in one of the following ways: 

If the Department of Health (DOH) has not designated the clinic as a hospital-based entity, the clinic must submit to the agency a CMS-1500 claim form (version 02/12) or 837P claim form containing both:  

The facility and the professional fees in field 24F. The place of service (POS) 11 (office setting) in field 24B.

Medicare and Medicaid policy prohibit the hospital from billing a facility fee in this circumstance. The agency will reimburse the clinic the nonfacility setting fee. This single claim comprises the total payment for the services rendered

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Physician-Related Services/Health Care Professional Services 

If DOH has designated the clinic as a hospital-based entity, for the agency to reimburse the clinic and the associated hospital for services provided to clients eligible for Washington Apple Health (Medicaid), the following must happen: 

The clinic must submit to the agency a CMS-1500 claim form (version 02/12) or 837P claim form containing both:  



The professional fees in field 24F. POS 22 (outpatient setting) in field 24B.

The hospital must submit to the agency a UB-04 or 837I claim form with the facility fees in form locator 47.

These two billings comprise the total payment for the services rendered. In the circumstances described above, clinics must follow instructions in this provider guide related to office setting and outpatient services.

How do I resolve issues with gender indicator when billing for transgender clients? For gender to procedure mismatch: for transgender female with male genitalia For a transgender client, providers must include a secondary diagnosis on the claim that indicates the client is transgender (F64.1, F64.8, F64.9). The secondary diagnosis may be in any diagnosis field on the claim. Use of the secondary diagnosis allows the gender-specific procedures to be processed through the agency’s claims system. Without the secondary diagnosis code, the claim may be denied. Example situation: A client self-identifies as a female but still has male specific body parts. This client then gets a routine prostate exam. This bill would deny for a male-only procedure being billed on a female client. However, if a diagnosis such as gender identity disorder was listed as the secondary diagnosis, the claim would then be processed for payment. Providers must list the secondary diagnosis (F64.1, F64.8, F64.9) on the claim in these circumstances. If a claim is denied for a gender mismatch, contact the agency’s Contact Us web page. Note: Providers should encourage transgender clients to update their gender listed on their Washington Apple Health account by contacting the agency’s Medical Eligibility Determination Services (MEDS) toll free 855-623-9357. CPT® codes and descriptions only are copyright 2015 American Medical Association

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ProviderOne gender indicator does not match claim gender indicator Such as when a client presents as a female but ProviderOne has the male gender indicator in file. The provider should check the client’s gender in ProviderOne when verifying coverage. If a mismatch is found, the provider should encourage the client to update the gender field to their preferred gender. The client can do this by calling the agency’s Medical Eligibility Determination Section toll-free 1-855-623-9357.

How does the provider notify the agency of a date of birth or gender mismatch? If a provider finds that a client’s date of birth or gender is incorrect, the provider should email the following information to the agency’s Contact Us web page.       

TCN # A comment that the client is transgender ProviderOne client ID Client’s name Date of birth Gender at birth Gender identified as at the time service provided

How does a client update their gender field? 

Clients who applied through the Healthplanfinder must call the agency’s Medical Eligibility Determination Section toll free 1-855-623-9357.



Clients who applied through the Community Service Office (CSO) must call toll-free 1-877-501-2233 or report online at Washington Connection.

Any Washington Apple Health client can call and choose a gender. Clients should be aware other state agencies, such as the Department of Licensing, have different requirements.

How does a client update or change their name? Before making a name change, the client should first obtain a name change with Social Security. If the client’s name does not match the client’s name in Social Security, the system will generate an error and this could affect the client’s coverage. 

Clients who applied through the Healthplanfinder must call toll-free 1-855-623-9357.



Clients who applied through the Community Service Office (CSO) must call toll-free 1-877-501-2233 or report online at Washington Connection. CPT® codes and descriptions only are copyright 2015 American Medical Association

339

Physician-Related Services/Health Care Professional Services If providers have any concerns or question regarding the policy with this new benefit, please contact the agency by email at [email protected]

How do I complete the CMS-1500 claim form? Instructions on how to bill professional claims and crossover claims electronically can be found on the Medicaid Providers Training page under Medicaid 101. Also, see Appendix I of the agency’s ProviderOne Billing and Resource Guide for general instructions on completing the CMS-1500 claim form (version 02/12).

Submitting professional services on a CMS-1500 claim form for Medicare crossovers For services paid for, and/or applied to, the deductible by Medicare: 

Medicare should forward the claim to the agency. If the claim is not received by the agency, please resolve that issue prior to billing a paper claim to reduce the possibility of claim denial and the need to resubmit.



Complete the claim form as if billing for a non-Medicare client.



Always attach the Medicare Explanation of Medicare Benefits (EOMB).



Do not indicate any payment made by Medicare in field 29. Enter only payments made by non-Medicare, third-party payers (e.g., Blue Cross) in field 29 and attach the Explanation of Benefits (EOB). Note: If Medicare allowed/paid on some services and denied other services, the allowed/paid services must be billed on a different claim than the denied services. Exception: When billing crossover claims for Indian Health Services, follow the instructions in the agency’s Tribal Health Program Provider Guide.

Requirements for the provider-generated EOMB to process a crossover claim Header level information on the EOMB must include all the following:     

Medicare as the clearly identified payer The Medicare claim paid or process date The client’s name (if not in the column level) Medicare Reason codes Text in font size 12 or greater CPT® codes and descriptions only are copyright 2015 American Medical Association

340

Physician-Related Services/Health Care Professional Services Column level labels on the EOMB for the CMS-1500 claim form (version 02/12) must include all the following:           

The client’s name Date of service Number of service units (whole number) (NOS) Procedure Code (PROC) Modifiers (MODS) Billed amount Allowed amount Deductible Amount paid by Medicare (PROV PD) Medicare Adjustment Reason codes and Remark codes Text that is font size 12

Utilization review Utilization Review (UR) is a concurrent, prospective, and/or retrospective (including post-pay and pre-pay) formal evaluation of a client’s documented medical care to assure that the health care services provided are proper and necessary and are of good quality. The review considers the appropriateness of the place of care, level of care, and the duration, frequency, or quantity of health care services provided in relation to the condition(s) being treated. The agency uses InterQual® ISDR Level of Care Criteria as a guideline in the utilization review process.     

Concurrent UR is performed during a client’s course of care. Prospective UR is performed prior to the provision of health care services. Retrospective UR is performed following the provision of health care services and includes both post-payment and pre-payment review. Post-payment retrospective UR is performed after health care services are provided and paid. Pre-payment retrospective UR is performed after health care services are provided but prior to payment.

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Provider Guide - Washington State Health Care Authority

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