PHYSICIAN-RELATED SERVICES/ HEALTH CARE PROFESSIONAL SERVICES Provider Guide April 1, 2014 Physician-Related Services/Health Care Professional Services About this guide* This publication takes effect April 1, 2014, 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? Reason for Subject Change Change Nonemergency services Added policy information regarding nonemergency Added language out-of-state services provided out-of-state which mirrors WAC Substitute physicians Fixed link to United States Code Erroneous link Expedited Prior EPA# 1300 Injection, Romiplostim, 10 Microgram – AMGEN Authorization Removed requirement for prescriber and client to be discontinued enrolled in NEXUS Program. This change is NEXUS program, retroactive to 12/6/2011. 12/6/2011 Payment for blood and Removed CPT 88240 from list This code is not blood products covered. Payment for Primary Added policy for higher payment for certain primary Chapter 42.447.400 Care Providers care services RCW Rate Increase for Added policy for rate increase for independent ARNPs 3ESSB 5034, Sec. Independent ARNPS 213, Subsec. (26) & PN 14-19 Oral surgery coverage Removed CPT codes 13150 and 15320 CPT codes updates, table Added CPT codes 15275, 15278, 99242, 99244, 99252, policy changes, and 99254, 99255 added CPT codes SBIRT criteria Removed limitation of one (1) per client, per provider, Removed limit per per year CMS Smoking cessation Clarified process client must follow when Tobacco Housekeeping Quitline recommends a smoking cessation prescription Medical necessity Remove the limit of one per day for MRA, MRI, and All require medical review PETCT necessity reviews Pre-/intra- Removed chart. Added reference to Medicare’s online Too difficult to keep /postoperative payment Physician Fee Schedule. the chart up-to-date. splits Established patient Clarified billing requirements for CPT code 99211, Clarification visits which includes signature and date by a qualified health care professional who provided the service. * This publication is a billing instruction. 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 copyright 2013, 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. Physician-Related Services/Health Care Professional Services Table of Contents Definitions .......................................................................................................................................1 Introduction ....................................................................................................................................4 Acquisition cost (AC) ................................................................................................................4 Add-on codes .............................................................................................................................4 By report (BR) ...........................................................................................................................4 Codes for unlisted procedures ....................................................................................................5 Conversion factors .....................................................................................................................5 Diagnosis codes .........................................................................................................................5 Discontinued codes ....................................................................................................................5 National correct coding initiative...............................................................................................6 Procedure codes .........................................................................................................................6 Provider Eligibility.........................................................................................................................7 Who may provide and bill for physician-related services? ........................................................7 Can naturopathic physicians provide and bill for physician-related services? ..........................8 Can substitute physicians (locum tenens) provide and bill for physician-related services? ...............................................................................................................................9 Which health care professionals does the agency not enroll? ..................................................10 Does the agency pay for out-of-state hospital admissions? .....................................................11 Client Eligibility ...........................................................................................................................12 How can I verify a patient’s eligibility? ..................................................................................12 Are clients enrolled in managed care eligible for services? ....................................................13 Are clients enrolled in hospice eligible for services? ..............................................................13 Coverage - General ......................................................................................................................14 What is covered? ......................................................................................................................14 Does the agency cover nonemergency services provided out-of-state? ..................................16 What services are noncovered? ................................................................................................16 General information ...........................................................................................................16 Noncovered physician-related and health care professional services ................................17 Medical Policy Updates ...............................................................................................................19 Policy updates effective 7/1/2013 ............................................................................................19 Policy updates effective 4/14/2013 ..........................................................................................19 Policy updates effective 4/1/2013 ............................................................................................19 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.) Physician-Related Services/Health Care Professional Services Evaluation and Management (E/M) ...........................................................................................20 E/M documentation and billing ...............................................................................................20 PAL (Partnership Access Line) ...............................................................................................20 Office and other outpatient services ........................................................................................21 Office or other outpatient visit limits .................................................................................21 New patient visits ...............................................................................................................21 Established patient visits ....................................................................................................21 Nursing facility services ....................................................................................................21 Pre-operative visit prior to performing a dental service under anesthesia .........................22 Physical examination - clients of the DSHS’ Developmental Disabilities Administration .............................................................................................................22 Office visit related to Acomprosate, Naltrexone, Buprenorphyine, Nalozone ..................22 Behavior change intervention - smoking cessation .................................................................22 Services available...............................................................................................................23 Washington State Tobacco Quitline ..................................................................................23