Outpatient Hospital Services Billing Guide

Washington Apple Health (Medicaid)

Outpatient Hospital Services Billing Guide

July 1, 2020

Disclaimer

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. Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the guide. If this is the most recent guide, please notify us at askmedicaid@hca..

About this guide1

This publication takes effect July 1, 2020, and supersedes earlier guides to this program. Refer to Chapter 182-550 WAC for more information. 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 1-800-562-3022. 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 state-only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority.

Services, equipment, or both, related to any of the programs listed below must be billed using their specific billing guides: ? Inpatient Hospital Services ? Physician-Related Services/Health Care Professional Services

1 This publication is a billing instruction.

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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How can I get agency provider document?

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's form number into the Search box as shown below (Example: 13-835).

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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.

What has changed?

Subject

Change

Reason for Change

Entire guide

Revised format of entire guide

To comply with accessibility standards

Are clients enrolled in an agencycontracted managed care organization (MCO) eligible?

Changed third bullet in section to read: "Dental procedures when billed with a CDT or CPT procedure code with revenue code 0360 or 0361."

To further clarify which procedures MCOs are responsible to pay for

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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Subject

Whole exome sequencing

Change Added section

Reason for Change New agency policy

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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Table of Contents2

Definitions ......................................................................................................................... 10 About the Program ....................................................................................................... 13

What is the purpose of the outpatient hospital services program? .... 13 How does medical necessity apply to outpatient hospital services? .. 13 What about outpatient hospital services provided within one calendar day of paid inpatient admission?........................................................................ 13 Client Eligibility ............................................................................................................... 14 How do I verify a client's eligibility?.................................................................. 14 Are clients enrolled in an agency-contracted managed care organization (MCO) eligible?................................................................................ 15

Managed care enrollment.................................................................................. 16 Apple Health ? Changes for January 1, 2020 ................................................. 17

Clients who are not enrolled in an agency-contracted managed care plan for physical health services ..................................................................... 18 Integrated managed care (IMC) ...................................................................... 18 Integrated managed care regions .................................................................. 20 Integrated Apple Health Foster Care (AHFC) ............................................ 21 Fee-for-service Apple Health Foster Care ................................................... 21 Admissions........................................................................................................................ 22 What are the criteria for an outpatient short stay? .................................... 22 What is admission status? ...................................................................................... 22 When to change admission status ................................................................. 23 Changing status from inpatient to outpatient observation................ 23 Changing status from outpatient observation to inpatient................ 23

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

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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Changing status from inpatient or outpatient observation to outpatient ................................................................................................................. 24 Changing status from outpatient surgery/procedure to outpatient observation or inpatient ..................................................................................... 25 Surgery ............................................................................................................................... 26 Surgical and medical procedures and evaluations...................................... 26 Cochlear implants and bone conduction hearing devices....................... 26 Replacement parts or repairs for cochlear implants and bone conduction hearing devices .............................................................................. 26 Corneal tissue .............................................................................................................. 27 Robotic assisted surgery (RAS) ............................................................................ 27 Skin substitutes........................................................................................................... 27 Vagus nerve stimulator ........................................................................................... 27 Radiology........................................................................................................................... 29 Radiology guidelines and procedures .............................................................. 29 Pathology and Laboratory ......................................................................................... 30 Breast and/or ovarian genetic testing .............................................................. 30 Gene expression profile testing........................................................................... 30 Pathology and laboratory guidelines................................................................ 30 Pharmacogenetic testing guidelines ................................................................. 30 Shingles vaccine when administered in outpatient hospitals ................ 30 Testosterone testing................................................................................................. 30 Whole exome sequencing...................................................................................... 30 Mental Health .................................................................................................................. 31 When does an MCO pay for an outpatient hospital visit for a client with a psychiatric principal diagnosis? ............................................................. 31 Office and Other Outpatient Services ................................................................... 32 COVID-19 ....................................................................................................................... 32 Diabetes Education ................................................................................................... 32 Drugs professionally administered .................................................................... 33

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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Hyaluronic acid/viscosupplementation ....................................................... 33 Rabies immune globulin (RIG) ......................................................................... 33 National drug code format................................................................................ 33 Herpes Zoster (Shingles) vaccine.................................................................... 33 SpinrazaTM.................................................................................................................. 33 Drug screening............................................................................................................ 34 Drug screening for medication assisted treatment (MAT) and substance use disorders (SUD) ........................................................................ 34 Additional information when prescribing (Suboxone?) ..................... 34 Fecal microbiota transplantation ........................................................................ 34 Foot care services....................................................................................................... 34 Imaging for rhinosinusitis ...................................................................................... 35 Radiopharmaceutical diagnostic imaging agents ....................................... 35 Kidney centers............................................................................................................. 35 Medical genetics and genetic counseling services...................................... 35 Medical nutrition therapy ...................................................................................... 35 Neurodevelopmental providers .......................................................................... 35 Occupational therapy, physical therapy, or speech/audiology services ........................................................................................................................................... 36 Sleep medicine testing (sleep apnea) ............................................................... 36 Telemedicine................................................................................................................ 37 Treatment of chronic migraine and chronic tension-type headache.. 37 Varicose vein treatment .......................................................................................... 37 Vision care services ................................................................................................... 37 Centers of Excellence (COEs)..................................................................................... 38 Where can I find agency-approved COEs?...................................................... 38 What services must be performed in agency-approved COEs? ............ 38 Medical Necessity Review by Comagine Health............................................... 39 What is a medical necessity review by Comagine Health? ...................... 39

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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What imaging procedures require medical necessity review by Comagine Health? ..................................................................................................... 40 Authorization ................................................................................................................... 41 Prior authorization (PA) .......................................................................................... 41

What is PA?............................................................................................................... 41 How does the agency determine PA?........................................................... 42 Services requiring PA ........................................................................................... 42 How do I request PA? .............................................................................................. 42 Online submission by direct data entry into ProviderOne .................. 42 Written or fax request ......................................................................................... 42 Submission of photos and X-rays for medical and DME requests... 43 Limitation extension (LE) ........................................................................................ 43 What is an LE? ......................................................................................................... 43 How do I request an LE? ..................................................................................... 43 Documentation requirements for PA or LE .................................................... 44 How do I obtain PA or LE? ................................................................................. 44 Forms available to submit authorization requests.................................. 44 Forms available to submit authorization requests for medication.. 44 Outpatient prospective payment system (OPPS)............................................. 46 How does the agency pay for outpatient hospital services? .................. 46 How does the agency determine the payment method for OPPS?..... 46 What is the OPPS payment calculation?.......................................................... 47 OPPS payment enhancements......................................................................... 47 Billing................................................................................................................................... 49 What are the general billing requirements? .................................................. 49 What additional outpatient hospital billing requirements are there? 50 National correct coding initiative (NCCI) .................................................... 50 How are outpatient hospital services prior to admission paid? ............ 51

CPT? codes and descriptions only are copyright 2019 American Medical Association.

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