Physician-Related Services -- Health Care Professional ...

Washington Apple Health (Medicaid)

Physician-Related Services/Health Care Professional Services Billing Guide

July 1, 2019

Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply.

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About this guide*

This publication takes effect July 1, 2019, and supersedes earlier guides to this program.

The Health Care Authority (agency) is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-5623022. People who have hearing or speech disabilities, please call 711 for relay services.

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

Change

Reason for Change

Entire document

Housekeeping changes

To improve usability

Behavioral health organization (BHO)

Integrated managed care regions

Medical policy updates Pediatric Primary Care rate increase Telemedicine

Removed North Sound from list of Regional Service Areas

Effective July 1, 2019, a new integrated managed care region, called North Sound, will be implemented. North Sound region includes Island, San Juan, Skagit, Snohomish, and Whatcom counties. Added HTCC decision regarding PET scans for lymphoma Revised the end date for the primary care provider rate increase to be June 30, 2020

Added renal dialysis centers to the list of originating sites

Effective July 1, 2019, behavioral health services in the North Sound region will be provided under integrate managed care. New integrated managed care region

HTCC decision

See the agency's Pediatric primary care rate increase website for specific details. To comply with WAC 182-531-1730 filed under WSR 19-11-122 on 5/22/2019

* This publication is a billing instruction. 2

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Microprocessor-controlled lower limb prostheses Skin substitutes

Radiation oncology

Positron emission tomography (PET) scans for lymphoma STAT laboratory charges Testosterone testing

Centers of excellence

Injectable drugs ? limitations

Drugs administered to managed care clients but reimbursed through fee-forservice

Removed information about orthognathic surgery Added when the agency considers skin substitutes to be medically necessary for wound treatment, including limitation Updated medical necessity criteria for intensity modulated radiation therapy (IMRT). Removed information on EPA #870001313 Added section explaining when the agency covers PET scans for lymphoma Deleted CPT codes 80100, 80196, and 82003 from the table Added coverage of testosterone testing when it is part of the treatment for gender dysphoria or when it is for all females or males age 18 and younger Removed the section titled "Coverage for HEMLIBRA? (emicizumab-kxwh)"

Added procedure code J3398 (Luxturna)(VoretigemeNeparvovec-rzyl) to list of covered injectable drugs

Changed procedure code Q2040 to Q2042 for (Kymriah) Tisageneleucel-T suspension for IV infusion Added Lutathera (lutetium Lu 177 dotatate) to the table. Alphabetized list by "Label name" and added Gamifant, Revcovi, and Zolgensma to table

Information was in the wrong location To reflect current coverage policy

To clarify agency policy

HTCC decision

These codes were discontinued in 2014. To clarify agency policy

HCPCS code J3490 is no longer covered for the treatment of Hemophilia A. The agency now covers this drug.

To list the correct procedure code

Lutathera is now paid fee-for-service for clients of an agencycontracted MCO. To improve usability of document and reflect current agency policy

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Access to Baby and Child Dentistry (ABCD) Program

Edited "Training and certification" section and renamed it "Who may provide ABCD dentistry?"

To mirror policy published in the agency's ABCD Program Billing Guide

Removed table under "What dental services are billable by primary care medical providers" and moved it to a new section called "Dental services coverage table"

Modified and moved information under "Dental disease prevention services" to "What dental services are billable by primary care medical providers"

Oral surgery

EPA code 870001302 Hysterectomies for cancer

EPA code 870001368 Testosterone testing EPA code 870001374 Intensity modulated radiation therapy (IMRT)

Added a new section called "Topical fluoride treatment" Added links to Dental-Related Services and Orthodontic Services billing guides. Deleted CPT codes 11100 and 11101 from the Oral surgery coverage table Removed CPT codes 58545 and 58546 from list of appropriate CPT codes for this EPA code

Updated EPA criteria for testosterone testing

Updated EPA criteria for IMRT

To improve usability of document and remove discontinued codes

Codes are not hysterectomy codes that deal with cancer treatment To correct coverage criteria for testosterone testing To clarify agency policy

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How can I get agency provider documents?

To access provider alerts, go to the agency's Provider alerts webpage. To access provider documents, go to the agency's Provider billing guides and fee schedules webpage.

Where can I download agency forms?

To download an agency provider form, go to the agency's Forms & publications webpage. Type the agency form number into the Search box as shown below (Example: 13-835).

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2018, 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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In order to avoid copyright disputes, this page is only a partial summary.

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