Physician-Related Services/ Health Care Professional Services Provider Guide July 1, 2014 Physician-Related Services/Health Care Professional Services About this guide* This publication takes effect July 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 Allowable conditions of the Changed “Acute” in title to “Allowable” and added More accurately fits lower extremities by diagnosis code 703.8 the list of diagnosis diagnosis codes Antepartum visits - Removed diagnosis codes. Providers must bill Clarification Additional monitoring for with a primary diagnosis that identifies that the high risk conditions high risk condition is pregnancy related and which is within the provider’s scope of practice. Developmental screening Added “per client, per provider” to the limitation Clarified limitation for CPT code 96111. Expedited Prior Assigned an EPA number to Q4116 Alloderm and This procedure Authorization Criteria added it to the EPA list requires EPA Coding List Expedited Prior Added diagnosis code V74.1 to EPA# 1325 Clarified allowable Authorization Criteria diagnosis codes Coding List Facet neurotomy Updated policy. Removed erroneous diagnosis Align with policy code used by Qualis Health Habilitative services Removed list of qualifying diagnoses and added a Linking directly to qualifying diagnoses link to the agency’s Habilitative Services Provider original chart Guide reduces possibility for errors Hemophilia Treatment – Added HCPCS code J7199 to list of covered codes Policy change Coverage Table Integumentary System – The following procedure codes require prior Policy change Miscellaneous procedures authorization: CPT code 11980 and HCPCS code S0189 Mental Health Added new section on mental health with a cross New policy reference to the agency’s Mental Health Provider Guide * This publication is a billing instruction. Physician-Related Services/Health Care Professional Services What has changed? (cont.) Reason for Subject Change Change National correct coding Added reminder to providers to follow coding Clarification initiative guidelines in the CPT coding book Ostomy reconstruction Removed diagnosis code 170.1 This diagnosis code is not covered. Payment for blood and Removed CPT 88241 from list This code is not blood products covered. PSA screening Added “for clients 50 years of age or older” to the Clarified limitation limitation for HCPCS code G0103 Robotic assisted surgery Clarified language and removed diagnosis codes Clarification Sleep medicine testing Changed diagnosis code 327.00 to 347.00 in list of Wrong diagnosis (sleep apnea) approved diagnoses for sleep studies code listed 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 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 (DDA) .................................................................................................22 Office visit related to Acomprosate, Naltrexone, Buprenorphyine, Nalozone ..................22 Behavior change intervention - smoking cessation