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Provider Guide Physician-Related Services/ Health Care Professional Services Provider Guide July 1, 2015 Physician-Related Services/Health Care Professional Services About this guide* This publication takes effect July 1, 2015, 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 state- only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority. What has changed? Subject Change Reason for Change Medical Policy Updates Added updates from the Health Technology Clinical In accordance with WAC Committee (HTCC) 182-501-0055, the agency reviews the recommendations of HTCC and decides whether to adopt the recommendations Bariatric surgeries Removed list of agency-approved COEs and added Clarification link to web page for approved COEs Update to EPA Removed CPT 80102 CPT Code Update 870000050 Added CPT 80302 Maternity and delivery – Added intro paragraph for clarification of when to Clarification Billing with modifiers bill using modifier GB. Also updated column headers for modifiers Immune globulins Replacing deleted codes Q4087, Q4088, Q4091, and Updating deleted codes Q4092 with J1568, J1569, J1572, and J1561 Bilateral cochlear implant EPA 870001365 fixed diagnosis code 398.18 Corrected typo Newborn care The agency pays a collection fee for a newborn Clarification metabolic screening panel. The screening kit is provided free from DOH. Vaccines/Toxoids Add language “Routine vaccines are administered Clarification (Immunizations) according to current Centers for Disease Control (CDC) advisory committee on immunization practices (ACIP) immunization schedule for adults and children in the United States.” Injectable and nasal flu Adding link to Injectable Fee Schedule for coverage Clarification vaccines details * This publication is a billing instruction. - 2 - Physician-Related Services/Health Care Professional Services Subject Change Reason for Change Requirements for The agency pays for developmental testing with This is a correction to the developmental & autism interpretation and report (CPT 96111) when provided agency’s payment system. surveillance and by agency-approved COEs. EPA# 870001367 is The agency is also sending screening required. a separate notice to the This is a correction to the agency’s payment system. COEs regarding this. Providers may resubmit any denied bills for this service to the agency. The agency will review and process claims for payment retroactively for dates of service on and after January 1, 2014. E/M Documentation and Added additional clarification when billing for E/M Clarification Billing codes Testosterone testing Added coverage for testosterone testing with HTCC Final Findings and conditions. EPA# 870001368 is required. Decision for testosterone testing Billing for single-dose Removed “…including partial vials.” Clarification vials Mental Health Added new section regarding services provided to Billing clarification the MCO client during RSN-approved admissions Added two new EPA#s 870001369, 870001370 with coverage criteria Vision therapy Added two new EPA#s 870001371 and 870001372 New EPA requirements for orthoptics/pleoptic training (CPT code 92065) when there is a secondary diagnosis of traumatic brain injury (TBI). Transgender Health New section regarding coverage of service related to New coverage policy Services transgender health and the treatment of gender (WAC 182-531-1675) dysphoria 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. - 3 - Physician-Related Services/Health Care Professional Services Copyright disclosure Current Procedural Terminology copyright 2014, American Medical Association. 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. - 4 - Physician-Related Services/Health Care Professional Services Table of Contents Definitions .....................................................................................................................................18 Introduction ..................................................................................................................................21 Acquisition cost (AC) ..............................................................................................................21 Add-on codes ...........................................................................................................................21 By report (BR) .........................................................................................................................21 Codes for unlisted procedures ..................................................................................................22 Conversion factors ...................................................................................................................22 Diagnosis codes .......................................................................................................................22 Discontinued codes ..................................................................................................................22 National correct coding initiative.............................................................................................23 Procedure codes .......................................................................................................................23 Provider Eligibility.......................................................................................................................24 Who may provide and bill for physician-related services? ......................................................24 Can naturopathic physicians provide and bill for physician-related services? ........................25 Can substitute physicians (locum tenens) provide and bill for physician-related services? .............................................................................................................................26 Resident Physicians ...........................................................................................................26 Which health care professionals does the agency not enroll? ..................................................27 Does the agency pay for out-of-state hospital admissions? .....................................................28 Client Eligibility ...........................................................................................................................29 How can I verify a patient’s eligibility? ..................................................................................29 Are clients enrolled in managed care eligible for services? ....................................................30 Are clients enrolled in hospice eligible for services? ..............................................................30 Coverage - General ......................................................................................................................31 What is covered? ......................................................................................................................31 Does the agency cover nonemergency services provided out-of-state? ..................................33 What services are noncovered? ................................................................................................33 General information ...........................................................................................................33 Noncovered physician-related and health care professional services ................................34 Medical Policy Updates ...............................................................................................................36 Policy updates effective 7/1/2015 ............................................................................................36 Policy updates effective 4/1/2015 ............................................................................................36 Policy updates effective 1/1/2015 ............................................................................................36 Alert! The page numbers in this table of contents are now “clickable”—simply hover over on a page number and click to go directly to the page. As an Adobe (.pdf) document, the guide also is easily navigated by using bookmarks on the left side of the document. (If you don’t immediately see the bookmarks, right click on the document and select Navigation Pane Buttons. Click on the bookmark icon on the left of the document.) - 5 - Physician-Related Services/Health Care Professional Services Policy updates effective 10/1/2014 ..........................................................................................36 Evaluation and Management (E/M) ...........................................................................................37 E/M documentation and billing ...............................................................................................37 Advance
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